The impact of e-cigarettes and individual-level interventions on socio-economic inequalities in smoking cessation

Electronic cigarettes (e-cigarettes) and individual-level interventions may either exacerbate or reduce inequalities in smoking cessation depending on differential effectiveness according to socio-economic position (SEP). This thesis addressed three distinct but complementary objectives across five studies. First, study 1 involved a systematic review to examine whether interventions tailored for disadvantaged SEP moderated effectiveness for smoking cessation compared with non-SEP-tailored approaches. SEP-tailored interventions were no more effective than non-SEP-tailored interventions for smoking cessation among disadvantaged smokers. Second, studies 2 and 3 modelled population-level trends in e-cigarette usage by SEP. Study 2 found that from 2014 to 2017 in England, e-cigarette use i) was greater among advantaged smokers compared with lower SEP smokers but this difference lessened over time, ii) was similar during a quit attempt across SEP groups, and iii) increased among all long-term ex-smokers but was more common among more disadvantaged ex-smokers. Study 3 examined the long-term ex-smoker sub-group from 2014 to 2019 in greater detail. Up until 2019 e-cigarette use continued to increase and diverge by SEP, with greater use among more disadvantaged groups. Separate analyses of ex-smokers who quit smoking before 2011 found a small increase in e-cigarette use over time but no evidence of differences by SEP. The final, qualitative objective explored what lower SEP individuals thought about e-cigarettes for smoking cessation. Study 4 highlighted that participants were using an e-cigarette in their otherwise unsupported quit attempt for health reasons, to save money, for family, and for enjoyment. Study 5 participants found an individual-level smoking cessation intervention involving the offer of an e-cigarette to be acceptable, and highlighted barriers and enablers to participation. This thesis highlighted that SEP-tailored and non-SEP-tailored individual-level interventions are not currently equity positive, and that e-cigarettes could provide a route out of smoking for more disadvantaged and dependent smokers who cannot quit otherwise

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

Socio-demographic, smoking and drinking characteristics in GB: A comparison of independent telephone and face-to-face Smoking and Alcohol Toolkit surveys conducted in March 2022

Background: Due to the COVID-19 pandemic, from April 2020 data collection for the Smoking and Alcohol Toolkit Study (STS/ATS) shifted from a face-to-face to a telephone survey. In March 2022 a parallel face-to-face survey was conducted alongside the telephone survey to explore whether the change in data collection to telephone affected key sociodemographic, smoking alcohol use indicators. Methods: Cross-sectional representative surveys (one telephone and one face-to-face) of adults aged 16+ in Great Britain. We estimated unweighted statistics and 95% confidence intervals for sociodemographic date. We estimated weighted prevalence statistics and 95% confidence intervals for selected smoking and alcohol use measures for Great Britain, England, Scotland and Wales separately, except nicotine product use, which was assessed for the overall Great Britain sample only. Results: In March 2022, 2,607 and 2,064 adults aged 16+ participated in respective telephone and face-to-face surveys for the STS/ATS. The unweighted age profile of the face-to-face wave was younger than the telephone wave but similar according to other sociodemographic variables. Weighted estimates in the telephone and face-to-face surveys differed by around one percentage point or less for response categories of daily smoker, non-daily smoker, pipe/cigar smoker, and stopped last year. There were differences in the estimates for never smoking and stopped more than a year ago between the surveys but the combined estimate for never or long-term ex-smoking was similar. Data on use of nicotine products by past-year smokers were similar between survey modalities. The estimates for people reporting an AUDIT score of 8 or higher, or an AUDIT-C score of 5 or higher, and attempting to cut down on drinking were similar between modalities. A higher proportion of respondents reported never drinking during the past year in the face-to-face survey compared with the telephone survey. Conclusion: A parallel telephone and face-to-face survey wave of the STS/ATS yielded similar estimates for key sociodemographic, smoking and alcohol use measures. Differences between estimates are generally within expected limits given the uncertainty of month-to-month surveys

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

Abstract 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

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 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

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)

Protocol for expansion of an existing national monthly survey of smoking behaviour and alcohol use in England to Scotland and Wales:The Smoking and Alcohol Toolkit Study

Background The Smoking and Alcohol Toolkit Study (STS/ATS) in England has delivered timely insights to inform and evaluate strategies aimed at reducing tobacco smoking- and alcohol-related harm. From the end of 2020 until at least 2024 the STS/ATS is expanding to Scotland and Wales to include all constituent nations in Great Britain. Expanding data collection to Scotland and Wales will permit the evaluation of how smoking and alcohol related behaviours respond to divergent policy scenarios across the devolved nations. Methods The STS/ATS consists of monthly cross-sectional household interviews (computer or telephone assisted) of representative samples of adults in Great Britain aged 16+ years. Commencing in October 2020 each month a new sample of approximately 1700 adults in England, 450 adults in Scotland and 300 adults in Wales complete the survey (~n = 29,400 per year). The expansion of the survey to Scotland and Wales has been funded for the collection of at least 48 waves of data across four years. The data collected cover a broad range of smoking and alcohol-related parameters (including but not limited to smoking status, cigarette/nicotine dependence, route to quit smoking, prevalence and frequency of hazardous drinking, attempts and motivation to reduce alcohol consumption, help sought and motives for attempts to reduce alcohol intake) and socio-demographic characteristics (including but not limited to age, gender, region, socio-economic position) and will be reviewed monthly and refined in response to evolving policy needs and public interests. All data analyses will be pre-specified and available on a free online platform. A dedicated website will publish descriptive data on important trends each month. Discussion The Smoking and Alcohol Toolkit Study will provide timely monitoring of smoking and alcohol related behaviours to inform and evaluate national policies across Great Britain

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. 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%CI 0.66-0.77) to 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 PR: 0.98, 95%CI 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