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

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

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

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

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

Trends in daily cigarette consumption among smokers: a population study in England, 2008-2023

Introduction: This study aimed to estimate time trends in cigarette consumption among smokers in England between 2008 and 2023 and to explore differences by key potential moderators. Aims and Methods: We used data from 57 778 adult cigarette smokers participating in a nationally representative monthly cross-sectional survey between January 2008 and September 2023. We estimated monthly time trends in mean daily consumption of (1) any, (2) manufactured, and (3) hand-rolled cigarettes among all smokers and by main type of cigarettes smoked, smoking frequency, age, gender, occupational social grade, region, nicotine replacement therapy use, and vaping status. Results: Overall cigarette consumption fell from 13.6 [95% CI = 13.3 to 13.9] to 10.6 [10.5 to 10.8] per day between January 2008 and October 2019 (a 22% decrease), then remained stable up to September 2023. Over this period, the proportion mainly or exclusively smoking hand-rolled cigarettes increased (from 30.6% [29.1%–32.1%] in 2008 to 52.1% [49.7%–54.5%] in 2023). As a result, manufactured cigarette consumption fell by 47%, from 9.5 [9.2–9.8] per day in January 2008 to 5.0 [4.7–5.3] in September 2023, while hand-rolled cigarette consumption increased by 35%, from 4.2 [3.9–4.4] to 5.6 [5.3–5.9], respectively. The decline in overall cigarette consumption was observed across all subgroups, but was greater among non-daily smokers, younger smokers, and those who vaped. Conclusions: Over the last 15 years, the average number of cigarettes consumed each day by smokers in England has fallen by almost a quarter, but has plateaued since October 2019. There has been a sharp decline in the number of manufactured cigarettes consumed and an increase in the number of hand-rolled cigarettes consumed, as smokers have increasingly shifted towards using hand-rolled tobacco. Implications: While average cigarette consumption in England has fallen over the past 15 years, this declining trend has stalled (and reversed in some population groups) since 2019. The availability of cheap, hand-rolled tobacco appears to be undermining policies that aim to reduce smoking by raising the price of tobacco (eg, through taxation) and could be targeted to reignite the decline in cigarette consumption

Evaluation of the impact of a regional educational advertising campaign on harm perceptions of e-cigarettes, prevalence of e-cigarette use, and quit attempts among smokers

INTRODUCTION: We evaluated how effective an advertising campaign that was piloted by Cancer Research UK in January/February 2018 was at promoting quit attempts by increasing awareness of the relative harms of e-cigarettes compared with smoking. METHODS: Adults (≥16 years, n = 2217) living in Greater Manchester (campaign region) and Yorkshire & Humber and the North East of England (control regions) completed cross-sectional surveys immediately before and after the campaign period. Surveys measured socio-demographics, perceptions and use of e-cigarettes, and motivation and attempts to quit smoking. We tested interactions between time (pre, post) and region (campaign, control). RESULTS: 36.7% (95% CI 33.0%-40.6%) of those in the intervention region recognised the campaign. In the general population, interactions were non-significant for all outcomes except for perception of e-cigarettes as effective cessation aids, with smaller increases from pre- to post-campaign in the campaign (49.9% to 54.0%) compared with the control region (40.5% to 55.0%; OR = 0.66, 95% CI 0.45-0.98). Among smokers, motivation to quit increased in the intervention region (44.0% to 48.0%) but decreased in the control region (40.5% to 21.5%; OR = 2.97, 95% CI 1.25-7.16), with no other significant differences between regions over time. A Bayesian analysis confirmed that non-significant results were inconclusive. CONCLUSIONS: Compared with the control region, the campaign was associated with an increase in smokers' motivation to quit but a smaller increase in adults' perception of e-cigarettes as an effective cessation aid. There was insufficient evidence to determine whether the campaign affected other outcomes

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

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.Keywords: illegal tobacco products; non-cigarette tobacco products; public policy