Among smokers from Great Britain over a quarter (27.8%) have never tried NRT, e‑cigarettes or HTP. These smokers were more commonly from BME groups, were smoking fewer cigarettes per day and reported low motivation to stop smoking.
A few limitations are relevant to study results. Data were cross-sectional, collected online in English only and self-reported. Measures of smoking status, motivation to stop smoking and cigarettes smoked per day fluctuate (23) but were measured only at the time of the survey. Also, non-daily smokers were asked about cigarettes smoked per day, which could have biased their CPD measure. Participants’ recall of alternative nicotine products use could have been biased: for instance, new HTP might have been confused with e-cigarettes (12). Nevertheless, the validity of self‑reported ever use of NRT and e‑cigarettes—products that most smokers are aware of (24)—should be similar to the acceptable level of validity of self‑reported smoking status (25).
Three out of four participants have tried at least one alternative nicotine product. The proportion of smokers who have tried HTP was 4.9%—similar to the 4.1% from the same survey in 2017 (12). NRT has been on the market for around 50 years and e‑cigarettes only for a decade, but substantially fewer smokers have ever tried NRT than e‑cigarettes. Vaping mimics behavioural, social and psychological aspects of smoking better than NRT use (26), which might explain current smokers’ preference for the newer product.
Alternative nicotine products can help to facilitate changes in smoking behaviour, but it does not imply that all participants who had tried them did so to reduce or stop smoking. Smokers try and use NRT for reasons other than reducing or stopping smoking (27), and many try e‑cigarettes out of curiosity (11). Likewise, never use of alternative nicotine products does not mean smokers are not trying to stop smoking: they might instead choose behavioural and/or medicinal support, or no support at all. Nevertheless, smokers who use alternative nicotine products have been shown to be more motivated to stop and have higher chances to stop smoking (28).
Smokers who had and had not tried alternative nicotine products did not differ in gender, age or socioeconomic status, which confirms that e‑cigarettes (29) and NRT (30) are equally used by smokers from different socioeconomic backgrounds. However, smokers from BME groups were less likely to have ever tried alternative nicotine products than smokers from White ethnic groups. The post hoc analysis suggested that the difference may be due to low rates of trial in Asian smokers. More prevalent use of smokeless tobacco in South Asian groups (31) could account for the difference, but we did not collect data on this and sample sizes for different ethnicities were too small for firm conclusions. Our study is the first to highlight the disparity between White and BME smokers in Great Britain, but similar findings are common in studies from the United States (US). In the US, Black and Hispanic smokers are less likely to have ever used NRT (32) and e‑cigarettes (33) than White smokers, and the differences have been attributed to more positive attitudes towards smoking (33), poorer awareness of (34) and knowledge about alternative nicotine products (35) among BME smokers, possibly due to how they are marketed (36). Ethnicity is associated with different smoking and cessation behaviours (37), however, it is rarely accounted for in UK research on smoking and nicotine use.
Tobacco harm reduction enables smokers who do not want to or cannot stop smoking to reduce smoking-related health risks without completely ceasing to use nicotine (1). Some smokers are reluctant to try harm reduction because they overestimate health risks associated with nicotine or e-cigarette use (38, 39). Our findings suggest that harm reduction might also be less attractive to light smokers and those with low motivation to stop smoking. Non-daily and light smokers often do not crave nicotine or experience withdrawal (40), accordingly they may not perceive the need for alternative nicotine products and/or feel the investment worthwhile. Similarly, smokers who enjoy smoking and do not want to quit might not see the need to try alternative products. These findings are concerning, since during the last decade smokers in England have become less dependent and less likely to try quitting (41). Light smokers, whose numbers have been increasing in the UK and worldwide (42), struggle to stop smoking as much as heavier smokers (43) but receive less support from healthcare specialists (44). According to our findings, they are also less likely to self-select harm reduction, thus the question remains as to how to approach and support light or unmotivated smokers to stop smoking.
This is the first study to identify lower ever use of alternative nicotine products among smokers from BME groups in Great Britain. Future research should explore reasons for this difference, and smokers’ ethnic background should not be neglected when investigating disparities in tobacco harm reduction in Great Britain.