Effects of E-cigarettes, Heated Tobacco, and Nicotine Pouches on Cigarette Smoking

Since the invention of the electronic cigarette (e-cigarette) in 2003, there has been a shift in global nicotine markets. Instead of smoking tobacco cigarettes, people are increasingly turning to alternative nicotine products that avoid combustion, such as e-cigarettes, heated tobacco, and oral nicotine pouches. This thesis aims to understand (i) how and why people's choices of nicotine products have changed and (ii) what effects these changes have had on cigarette smoking prevalence and public health. The first five chapters examine the changing patterns of nicotine use in Great Britain from 2016 to 2022. E-cigarettes remain the most popular alternative nicotine product, with few (<0.5%) adults using heated tobacco or nicotine pouches. However, smokers’ perceptions of the harmfulness of e-cigarettes deteriorated following the 2019 outbreak of lung injury linked to cannabis vaping. There were also changes in the types of e-cigarettes people used. Up to 2020, rechargeable e-cigarettes with refillable tanks were the most widely used device type, but the popularity of disposable e-cigarettes grew rapidly from 2021 onwards, especially among young adults. Despite this, the prevalence of any inhaled nicotine use remained relatively stable, both overall and among young adults. The penultimate chapter reported results of a randomised trial. It found tentative evidence of the effectiveness of providing e-cigarettes alongside varenicline for smoking cessation. However, results were imprecise as the COVID-19 pandemic and recall of varenicline caused the trial to be stopped early. The final chapter reports a systematic review on heated tobacco, which found that switching from cigarettes to heated tobacco substantially lowers exposure to toxicants and carcinogens, but exposure may be higher compared with stopping all tobacco use. It found no randomised trials on heated tobacco for smoking cessation, but there was population-level evidence that declines in cigarette sales accelerated after heated tobacco was introduced in Japan

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

Sports, Gigs, and TikToks: Multi-Channel Advertising of Oral Nicotine Pouches

Oral nicotine pouches, which contain fewer harmful constituents than traditional tobacco products, are being increasingly marketed and sold. In this paper, we use images we collected in Great Britain between 2021 and 2023, along with a social media scan of Instagram and TikTok in 2023 to analyse the marketing strategies of these pouches on three key marketing channels — online media, sports sponsorships, and out-of-home advertising. Findings reveal the extensive use of visually appealing content, influencer partnerships, and event sponsorships that are potentially targeting young and naive audiences. Despite this, survey data indicates that nicotine pouch use in Great Britain remains minimal. However, a notable shift in public health impact could arise if these marketing efforts start to bear more fruit. The study underscores the need for balanced policy measures that increase access to reduced harm alternatives for existing tobacco and nicotine users while minimising exposure to youth and non-users. Continuous monitoring and regulatory adjustments are essential to address the evolving landscape of nicotine pouch marketing

Trends in use of e-cigarette device types and heated tobacco products from 2016 to 2020 in England

This study examined use trends of e-cigarette devices types, heated tobacco products (HTPs) and e-liquid nicotine concentrations in England from 2016 to 2020. Data were from a representative repeat cross-sectional survey of adults aged 16 or older. Bayesian logistic regression was used to estimate proportions and 95% credible intervals (CrIs). Of 75,355 participants, 5.3% (weighted = 5.5%) were currently using e-cigarettes or HTPs, with the majority (98.7%) using e-cigarettes. Among e-cigarette users, 53.7% (CrI 52.0–55.1%) used tank devices, 23.7% (22.4–25.1%) mods, 17.3% (16.1–18.4%) pods, and 5.4% (4.7–6.2%) disposables. Tanks were the most widely used device type throughout 2016–2020. Mods were second until 2020, when pods overtook them. Among all e-cigarette/HTP users, prevalence of HTP use remains rare (3.4% in 2016 versus 4.2% in 2020), whereas JUUL use has risen from 3.4% in 2018 to 11.8% in 2020. Across all years, nicotine concentrations of ≤ 6 mg/ml were most widely (41.0%; 39.4–42.4%) and ≥ 20 mg/ml least widely used (4.1%; 3.4–4.9%). Among e-cigarette/HTP users, ex-smokers were more likely than current smokers to use mod and tank e-cigarettes, but less likely to use pods, disposables, JUUL and HTPs. In conclusion, despite growing popularity of pods and HTPs worldwide, refillable tank e-cigarettes remain the most widely used device type in England

Moderators of the association between regular smoking exposure and motivation and attempts to quit: a repeat cross‐sectional study

AIMS: To estimate the associations between regular exposure to smoking by other people and motivation and attempts to quit among current smokers. To examine whether socio-demographic and other factors moderate these associations. DESIGN: A repeat nationally representative cross-sectional survey. Data were collected monthly between November 2014 and February 2019. SETTING: England. PARTICIPANTS: Current smokers aged ≥ 16 years from the Smoking Toolkit Study (N=15,136). MEASUREMENTS: Participants were asked whether other people regularly smoke in their presence, how motivated they were to quit, and whether they had made a quit attempt in the past year. Moderators assessed were occupation-based social grade, housing tenure, urges to smoke, high-risk alcohol consumption, and disability. Adjusted analyses included moderators, socio-demographic (age/sex/ethnicity/sexual orientation/marital status/children in household) and seasonal (quarter/year) confounders. FINDINGS: Current smokers who were regularly exposed to other people smoking in their presence were less likely to be highly motivated to quit (odds ratio = 0.88 [95%CI 0.80-0.97]), but were no less likely to have made a quit attempt in the past year (OR 1.04 [0.97-1.13], Bayes Factor (BF) = 0.05). The inverse relationship between regular smoking exposure and motivation to quit was moderated by urges to smoke, such that exposure was only associated with a reduction in motivation among those without strong urges to smoke (OR 0.83 [0.75-0.93] versus OR 1.04 [0.86-1.26]; p = .048). None of the other factors significantly moderated the association with motivation to quit, and none moderated the relationship between regular smoking exposure and quit attempts. All non-significant interactions, except social grade (BF = 1.44) with quit attempts, had Bayes Factors that supported the hypothesis of no moderation (BF range: 0.12-0.21). CONCLUSIONS: Among current smokers in England, regular exposure to other smokers appears to be associated with lower motivation to quit in people without strong urges to smoke, yet there appears to be no association with quit attempts in the previous year. Social grade, housing tenure, high-risk alcohol consumption and disability do not moderate these associations

Differences between ethnic groups in self-reported use of e-cigarettes and nicotine replacement therapy for cutting down and temporary abstinence: A cross-sectional population-level survey in England

Background and aims: The National Institute for Health and Care Excellence (NICE) has called for research into tobacco harm reduction across ethnicities, genders and socio-economic status. Although there is increasing research focused on the latter two, relatively few studies have considered ethnic variations. Therefore this study aimed to assess (i) the association between ethnicity and use of e-cigarettes and nicotine replacement therapy (NRT) for temporary abstinence and cutting down, and (ii) trends in prevalence of these over time. Design: Repeated cross-sectional household survey. Setting: England. Participants: Between April 2013 and September 2019, data were collected on 24 114 smokers, 16+ of age, taking part in the Smoking Toolkit Study (STS). Measurements: Ethnicity coding included: White, mixed/multiple ethnic group, Asian, Black and Arab/other ethnic group. Smokers reported whether they were currently using e-cigarettes and/or NRT for cutting down or during periods of temporary abstinence. Findings: Odds of e-cigarette use for cutting down and temporary abstinence were significantly lower among those of Asian ethnicity (OR = 0.79, 95% CI = 0.66–0.93) and Arab/other ethnicity (OR = 0.58, 95% CI = 0.40–0.83) compared with White ethnicity. Those of mixed/multiple ethnicity had higher odds for NRT us (OR = 1.42, 95% CI = 1.04–1.94) compared with those of White ethnicity. Trend analysis indicated that for White ethnicity, e-cigarette use by smokers for cutting down and temporary abstinence followed an ‘inverse S’ shaped cubic curve indicating an overall rise, whereas NRT use followed an ‘S’ shaped cubic curve, indicating an overall decline. For mixed/multiple ethnicity a similar trend was found for NRT use only, with other ethnicities showing no statistically significant trends (suggesting relative stability over time). Conclusions: In England, e-cigarette use by smokers for cutting down and temporary abstinence is less common among Asian and Arab/other ethnicity smokers compared with White smokers. Smokers of mixed/multiple ethnicity are the most likely to be using NRT compared with other ethnic groups for cutting down and temporary abstinence. E-cigarette use by smokers for cutting down and temporary abstinence has increased over time among White smokers, whereas prevalence in other ethnic groups has remained stable

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

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 (≥18y) 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% to 0.32%; Prevalence ratio [PR]=2.22, 95%CI=1.33-3.70). Pouch use was four times more common among men than women (0.42% versus 0.09%; PR=4.55, 95%CI=2.27-9.09) but less common in older age groups (p1y) 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% versus 0.15%; PR=10.59, 95%CI=5.74-19.52) and nicotine replacement therapy users (2.02% versus 0.21%; PR=9.75, 95%CI=4.64-20.49). CONCLUSIONS: One in 400 adults in Great Britain use nicotine pouches, but 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