Does non-smoker identity following quitting predict long-term abstinence? Evidence from a population survey in England

Aims: ‘Categorical self-labels’ (e.g. thinking of oneself as a smoker or non-smoker) are important aspects of identity that can have a fundamental influence on behaviour. To explore the role identity aspects relating to smoking can play in smoking cessation and relapse, this study assessed the prospective associations between taking on a non-smoker identity following quitting and long-term abstinence.  Methods: A representative sample of 574 ex-smokers in England who quit smoking in the past year was followed-up at three (N=179) and six months (N=163). Post-quit identity relating to smoking (‘I still think of myself as a smoker’ or ‘I think of myself as a nonsmoker’), and demographic and smoking-related characteristics were assessed at baseline. Self-reported smoking abstinence was assessed at follow-ups.  Results: Non-smoker identity was reported by 80.3% (95%CI 76.8-83.4) of recent exsmokers. Younger age (p=0.017) and longer abstinence (p<0.001) were independently associated with a post-quit non-smoker identity. After adjusting for covariates, non-smoker identity (p=0.032) and length of abstinence at baseline (p<0.001) were associated with continued abstinence at three months follow-up, and baseline length of abstinence (p=0.003) predicted continued abstinence at six months.  Conclusions: The majority of people who quit smoking recently consider themselves as nonsmokers. Younger people and those who have been abstinent for longer are more likely to take on a non-smoker identity. Ex-smokers who make this mental transition following a quit attempt appear more likely to remain abstinent in the medium term than those who still think of themselves as smokers

Examining the influence of tobacco control mass media campaign expenditure on the association between motivation to stop smoking and quit attempts: A prospective study in England

OBJECTIVE: To explore whether expenditure on national tobacco control mass media campaigns moderates the association between motivation to stop smoking and future quit attempts. METHOD: Data were from 2601 people who smoke participating in a population survey with 12-month follow-up between April 2015 and February 2021. We used logistic regression to test associations of (i) baseline level of motivation to stop smoking, (ii) mean monthly tobacco control mass media campaign expenditure in England between baseline and follow-up, and (iii) their interaction, on past-year quit attempts assessed at 12-month follow-up. Covariates included age, sex, occupational social grade, and region. RESULTS: Between baseline and follow-up, 38.6% of participants made a quit attempt. Each one-point increase in baseline motivation to stop smoking was associated with 1.37 times greater odds (95%CI = 1.31-1.43) of making a quit attempt over 12-month follow-up. Each one standard deviation increase in tobacco control mass media expenditure between baseline and 12-month follow-up was associated with 13% greater odds of making a quit attempt (95%CI = 1.05-1.23). There was no significant interaction between mass media expenditure and motivation to stop on quit attempts (OR = 1.01, 95%CI = 0.97-1.05); the data provided strong evidence for the null (Bayes factors = 0.07 and 0.04 based on expected effect sizes of OR = 1.5 and OR = 0.67, respectively). CONCLUSIONS: Among people who smoke, self-reported level of motivation to stop strongly predicted whether they made a quit attempt in the subsequent year. Increased expenditure on tobacco control mass media campaigns was associated with increased quit attempts. The association between motivation and quit attempts did not differ according to tobacco control mass media expenditure over this period

Facilitators and barriers for harm reduction after first use of novel nicotine delivery devices: a qualitative investigation of cigarette smokers

BACKGROUND: Novel nicotine delivery devices (NNDDs) are a safer alternative to combustible tobacco smoking. Understanding what factors can facilitate people who smoke to use NNDDs can inform intervention design and public health messaging. This study aims to explore the facilitators and barriers to NNDD use from the perspective of smokers without prior use, after trialling two NNDDs. METHOD: UK adults who smoke combustible cigarettes (n = 11) were recruited from a larger quantitative study after trialling two NNDDs, an electronic cigarette and a heated tobacco product (order randomly allocated). Semi-structured interviews were conducted, transcribed and thematically analysed, using the COM-B model of behaviour and NVivo12 pro software. RESULTS: Five main themes were identified: health knowledge, availability of and accessibility to NNDD products, cost, social acceptance, and NNDD use experience. There was curiosity and interest in the uptake and use of NNDDs, but the absence of centralised product information was identified as a barrier. Other themes were related to the design and functionality of the NNDD products. For example, the e-cigarette with its low maintenance was seen as easier to use than the heated tobacco product, which offered too short a single use duration and was described as ‘cumbersome’. Throat discomfort and high anticipated cost were among additional barriers identified for both product types. CONCLUSION: This study highlights the need for reliable objective information on the health effects of NNDDs compared with combustible cigarettes, which could facilitate their regular use. Product adjustment such as single use duration alignment with combustible cigarette smoking duration may encourage uptake. Interventions offering opportunity for experience of NNDD use and knowledge dissemination of NNDDs could increase motivation to adopt harm reducing behaviours as demonstrated in this study

Willingness to get vaccinated initially and yearly against COVID-19 and its association with vaccine hesitancy, vaccine knowledge and psychological well-being: a cross-sectional study in UK adults

OBJECTIVES: This study explores the association between vaccine hesitancy, vaccine knowledge and psychological well-being with (1) receipt of/willingness to receive an initial vaccine against COVID-19, and (2) willingness to get vaccinated yearly against COVID-19. The importance of different vaccine attributes (eg, vaccine technology, effectiveness, side effects) to choose a specific COVID-19 vaccine was also assessed. DESIGN: Cross-sectional survey administered during May to June 2021 on vaccine hesitancy, vaccine knowledge, psychological well-being, willingness to receive COVID-19 vaccines, sociodemographics and COVID-19-related factors. SETTING: UK. PARTICIPANTS: A self-selected sample of 1408 adults. OUTCOME MEASURES: Receipt of/willingness to receive COVID-19 vaccine for the first time and yearly. RESULTS: Receipt of/willingness to receive a vaccine against COVID-19 initially and yearly were high (97.0% and 86.6%, respectively). Vaccine hesitancy was negatively associated with receipt of/willingness to receive vaccine initially/yearly (adjusted OR (aOR)=0.09, 95% CI 0.04 to 0.26, p<0.001/aOR=0.05, 95% CI 0.03 to 0.09, p<0.001). Vaccine knowledge and psychological well-being were positively associated with willingness to receive a yearly vaccine (aOR=1.81, 95% CI 1.43 to 2.29, p<0.001 and aOR=1.25, 95% CI 1.02 to 1.51, p=0.014, respectively), and general vaccine knowledge also with receipt of/willingness to receive vaccine initially (aOR=1.69, 95% CI 1.18 to 2.42, p=0.004). Vaccine effectiveness was the most important attribute for participants to choose a specific COVID-19 vaccine. CONCLUSIONS: Improving vaccine knowledge and emphasising vaccine efficacy may minimise vaccine hesitancy and increase COVID-19 vaccine uptake

The association of smoking status with SARS-CoV-2 infection, hospitalisation and mortality from COVID-19: A living rapid evidence review (version 6)

Aims: To estimate the association of smoking status with rates of i) infection, ii) hospitalisation, iii) disease severity, and iv) mortality from SARS-CoV-2/COVID-19 disease. Design: Living rapid review of observational and experimental studies with random-effects hierarchical Bayesian meta-analyses. Published articles and pre-prints were identified via Ovid MEDLINE and medRxiv. Setting: Community or hospital with no restrictions on location. Participants: Adults who had received a test for SARS-CoV-2 infection or a diagnosis of COVID-19. Measurements: Outcomes were SARS-CoV-2 infection, hospitalisation, disease severity and mortality stratified by smoking status. Study quality was assessed. Findings: Version 6 with searches up to 17 July 2020 included 174 studies with 26 included in meta-analyses. Thirty-nine studies reported current, former and never smoking status. Notwithstanding recording uncertainties, compared with adult national prevalence estimates, recorded current smoking rates were generally lower than expected. Current compared with never smokers were at reduced risk of SARS-CoV-2 infection (RR = 0.74, 95% Credible Interval (CrI) = 0.56-0.97, τ = 0.46). Former compared with never smokers were at somewhat increased risk of infection but data were inconclusive (RR = 1.06, 95% CrI = 0.94-1.20, τ = 0.19). Current (RR = 1.05, CrI = 0.82-1.34, τ = 0.29) and former (RR = 1.20, CrI = 1.03-1.44, τ = 0.19) compared with never smokers were both at somewhat increased risk of hospitalisation with COVID-19, but data for current smokers were inconclusive. Current (RR = 1.15, CrI = 0.80-1.66, τ = 0.29) and former (RR = 1.51, CrI = 1.06-2.15, τ = 0.36) compared with never smokers were at increased risk of greater disease severity, but data for current smokers were inconclusive. Current (RR = 1.89, 95% CrI = 0.77-3.41, τ = 0.51) and former (RR = 1.93, 95% CrI = 1.33-2.66, τ = 0.19) compared with never smokers had increased risk of in-hospital death, but data for current smokers were inconclusive. Conclusions: There is uncertainty about the associations of smoking with COVID-19 outcomes. Recorded smoking prevalence among people with COVID-19 was generally lower than national prevalence. Current smokers were at reduced risk of infection. Former smokers were at increased risk of hospitalisation, disease severity and mortality, while data for current smokers favoured no important associations but were inconclusive.</jats:p

Impact of the cost-of-living crisis on the nature of attempts to stop smoking and to reduce alcohol consumption in Great Britain: A representative population survey, 2021-2022

BACKGROUND: Smoking and excessive drinking place a strain on household budgets. We aimed to examine the impact of the cost-of-living crisis in Great Britain on the nature of smoking cessation and alcohol reduction attempts, and explore changes in health professionals offering support. METHODS: Data were from 14,567 past-year smokers and high-risk drinkers (AUDIT-C ≥5) participating in monthly representative surveys, January-2021 through December-2022. We estimated time trends in cost as a motive driving the most recent (smoking cessation/alcohol reduction) attempt, use of paid or evidence-based support, and receipt of GP offer of support for smoking cessation or alcohol reduction, and tested for moderation by occupational social grade. RESULTS: The proportion of attempts motivated by cost did not change significantly over time among smokers (25.4% [95%CI = 23.8-26.9%]), but increased between December-2021 and December-2022 among high-risk drinkers from less advantaged social grades (from 15.3% [95%CI 12.1-19.3] to 29.7% [20.1-44.1]). The only change in support use was an increase in smokers using paid support, specifically e-cigarettes (from 28.1% [23.7-33.3] to 38.2% [33.0-44.4]). Among those visiting their GP, the proportion who received an offer of support was similar over time among smokers (27.0% [25.7-28.2]) and high-risk drinkers (1.4% [1.1-1.6%]). CONCLUSIONS: There is limited evidence that the 2021/22 cost-of-living crisis affected the nature of attempts to stop smoking and reduce alcohol consumption, or receipt of GP offer of support. It is encouraging that use of evidence-based support has not declined and that use of e-cigarettes in quit attempts has increased. However, cost is increasingly motivating alcohol reduction attempts among less advantaged drinkers, and rates of GPs offering support, especially for alcohol reduction, remain very low

How has expenditure on nicotine products changed in a fast-evolving marketplace? A representative population survey in England, 2018-2022

Introduction: In the last five 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, nicotine pouches) and describe changes between 2018 and 2022. / 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]/£15.96[15.49-16.28] among those who mainly smoked manufactured/hand-rolled cigarettes), e-cigarette users spent £6.30 [5.99-6.55] (£8.41[7.17-9.78]/£6.42[5.58-7.39]/£5.93[5.64-6.30] among those who mainly used disposable/pod/refillable devices), NRT users £6.11 [5.53-6.69], and heated tobacco users £13.87 [9.58-20.09]. Expenditure on cigarettes grew by 10% September-2018 to July-2020, then fell by 10% 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 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 nicotine replacement therapy. The average expenditure on manufactured cigarettes is double that of hand-rolled cigarettes

Patterns and predictors of adherence to health-protective measures during COVID-19 pandemic in the UK: cross-sectional and longitudinal findings from the HEBECO study

BACKGROUND: Adherence to health-protective behaviours (regularly washing hands, wearing masks indoors, maintaining physical distancing, carrying disinfectant) remains paramount for the successful control of COVID-19 at population level. It is therefore important to monitor adherence and to identify factors associated with it. This study assessed: 1) rates of adherence, to key COVID-19 health-protective behaviours and 2) the socio-demographic, health and COVID-19-related factors associated with adherence. METHODS: Data were collected on a sample of UK-based adults during August-September 2020 (n = 1,969; lockdown restrictions were eased in the UK; period 1) and November 2020- January 2021 (n = 1944; second UK lockdown; period 2). RESULTS: Adherence ranged between 50-95%, with higher adherence during the period of stricter measures. Highest adherence was observed for wearing masks indoors (period 1: 80.2%, 95%CI 78.4%-82.0%, period 2: 92.4%, 95%CI 91.1%-93.6%) and lowest for carrying own disinfectant (period 1: 48.4%, 95%CI 46.2%-50.7%, period 2: 50.7%, 95%CI 48.4%-53.0%). Generalized estimating equation models indicated that key factors of greater odds of adherence included being female, older age, having higher income, residing in England, living with vulnerable individuals and perceived high risk of COVID-19. CONCLUSIONS: Targeted messages to different demographic groups may enhance adherence to health-protective behaviours, which is paramount for the control of airborne respiratory diseases. PROTOCOL AND ANALYSIS PLAN REGISTRATION: The analysis plan was pre-registered, and it is available at https://osf.io/6tnc9/

Characterising smoking and smoking cessation behaviours 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 Researc