In this representative sample of adults in England ever regular use of NNP was almost entirely reported by current or ex-smokers, use of any type of nicotine product by non-smokers was minimal. Ever regular use of NRT was most prevalent, followed by e-cigarettes then heated tobacco products. Ever regular use of heated tobacco products was low and nobody in this survey reported ever regular use of the e-cigarette, JUUL.
These results extend the current literature in several ways. Firstly, it is important to monitor uptake and use of NNP across different groups including non-smokers; the results here corroborate other surveys and reviews showing that long-term or extended use of NNP is almost exclusively linked to past or current smoking (McNeill et al., 2019). This finding is important as there have been concerns that, especially e-cigarettes, may increase the appeal of nicotine use in never smokers but there is little evidence of ever regular use reported here. Second, ever regular NRT use was more prevalent than ever regular e-cigarette use. This may in part be explained by the much greater time period over which NRT has been available to be regularly used by a much larger cohort of people who were at the time it was available current smokers.
As has been found in other UK surveys of heated tobacco products, use of these products is very low in comparison with other NNP (McNeill et al., 2018). There are several plausible explanations for this relating to accessibility of the product (limited retail outlets) and also the price of the product. As heated-tobacco products are subject to higher duty, use of the product offers little price advantage, and as has been documented elsewhere, price is a key driver for product use and motivation to quit smoking (Jackson, Shahab, et al., 2019; Thirlway, 2016). Lastly, in relation to prevalence, nobody from just over 8000 people reported ever regular use of the e-cigarette JUUL. Concerns have been raised that the ‘gadgetry’ and ease of use of JUUL could appeal to non-smokers, especially young non-smokers (Fadus et al., 2019), but there is no evidence of regular use reported here, even among smokers and ex-smokers. It may be that this particular brand is not as appealing in competition with other well-established types of e-cigarette brands and other types of devices, e.g., tanks or other pods, which were widely used and available on the market before the launch of JUUL, and the UK has enacted stricter regulatory control around marketing compared to the US. Differences in trends of use between the UK and the US may also be attributed to the difference in nicotine strength availability (US 59mg/mL and UK up to 20mg/mL). However, monitoring trends in pod mods more broadly is useful as a number of smokers have reported not liking traditional tank devices or finding them difficult to use (Thirlway, 2016).
Use of multiple NNP was lower than single use. The design of this study means we are not able to infer cessation but if participants are using these products to quit smoking then use of a single product is potentially sub-optimal, as a recent Cochrane review of the evidence shows that use of two nicotine replacement products, fast acting combined with slow release, results in higher quit rates than single use (Lindson et al., 2019). Furthermore, a recently published randomised control trial by Walker et al., (2020) showed that use of an e-cigarette with nicotine e-liquid alongside a transdermal nicotine patch lead to modest but higher CO verified quit rates at 6-months compared with an e-cigarette with nicotine free e-liquid or a patch alone (7%, 4% and 2% respectively). We are also not able to assess how and in which combination the products were used. This is important future work, as the products available on the English market continue to grow, establishing which combination of products and how they are used may be most effective compared to single use is an important focus for future trials.
In relation to the sociodemographic associations, overall the results are in line with previously published work (Jackson, Hill, et al., 2019). Ever regular use of NNP was more prevalent in those from occupational grades ABC1 and use of alcohol to at least hazardous levels. Similarly, NRT was associated with female sex, older compared with younger 16-24-year-old adults and at least hazardous drinking. E-cigarettes were most commonly ever regularly used by younger adults and there is decline in use by age, again this has been reported elsewhere (Jackson, Hill, et al., 2019).
Those respondents from occupational social grades (C2DE) reported less ever regular e-cigarette use than those from more advantaged occupational grades (ABC1), but there was no social gradient effect in ever regular use of NRT. In England at the current time, smoking prevalence rates are twice as high in the least advantaged occupational grades compared with those in more advantaged professions (West, Kale, et al., 2020). Recent trial evidence has shown that e-cigarettes offered within the English stop smoking services provide the best chances of quitting tobacco and remaining abstinent at one year (Hajek et al., 2019), although the impact of e-cigarettes on reducing the social gradient of tobacco use are yet to be established. Nonetheless, regular use of e-cigarettes is associated with complete switching (Hitchman et al., 2015), so how best to encourage and support those people smoking from groups with a high smoking prevalence to both initiate e-cigarette use and to use their devices more regularly to prevent relapse to smoking and reduce concurrent tobacco use requires more consideration.
There is conflicting evidence on the use NNP (Smith et al., 2015), but here females report higher use of NRT. Evidence from across health sciences show men often require more encouragement to engage in formal health promoting interventions (Robertson et al., 2008). We also found an inverse association with age; this is not surprising given that these products have been widely available for a longer period of time. However, speculatively e-cigarettes may be more appealing to younger users than NRT and this could also reflect a diffusion of technology e.g., older smokers adopt e-cigarette use at a reduced pace compared with younger smokers. Lastly, in line with our recent work, a higher level of self-reported alcohol use was associated with NNP use and NRT (Jackson et al., 2020). This may indicate that users who are more nicotine dependent are more likely to drink alcohol. This may signal that for those smokers who drink alcohol regularly additional support is required to stop smoking and specifically tailored support to help them in situations when they are consuming alcohol and or they cannot smoke (i.e. for temporary abstinence).
This study offers a useful understanding of which groups are using NNP and how ever-regular use of one year or more is associated with current smoking status; however, there are some limitations. No causal or temporal associations with cessation can be made as this analysis is cross sectional only and we have not reported here why people were using these products, but this does lead to important questions for future research. We inferred a small sample (n = 7), of people currently using e-cigarettes were regular users – and therefore ever regular users – if they reported using products for more than 12 weeks (beyond standard length of time products are used for smoking cessation). Other limitations include potential recall bias, that is self-reporting is not always accurate, and regular use may be considered differently across individuals, future research should try to capture more granular patterns of use although this may be hard over more sustained periods of time. Our data was collected during the early part of the covid-19 pandemic in England, this may have impacted the sample or nature of information provided as respondents were interviewed by telephone instead of face-to-face.
Future studies should try to gain a more detailed pattern of regular use, especially key differences in the trajectory of ever regular use between current smokers, ex-smokers and dual users. That is, understanding how usage patterns, frequency and duration, are associated with helping people quit tobacco and remain quit. Furthermore, a high proportion of smokers report regularly using NRT and e-cigarettes, what is not known is whether these individuals reached a period of abstinence and then relapsed or whether they relapsed back to smoking. We observed clear effects of ever regular product use by age, and future research could focus on the distinct needs of older versus younger smokers, including whether e-cigarettes are not appealing to older smokers or whether lower uptake reflects products diffusion, or both. Lastly, there has been an increase in the number of smokers attempting to quit during the covid-19 pandemic 1, but also increased stress and uncertainty, so while smokers may be attempting to use NNP how this transfers into longer-term use over this unique period will require further monitoring.