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Aims: The United Kingdom and Australia have developed highly divergent policy responses to electronic nicotine delivery systems (ENDS). To understand the historical origins of these differences, we describe the history of tobacco control in each country and the key roles played in setting ENDS policy in its early stages by public health regulations and policy networks, anti‐smoking organizations, 'vaper' activist networks and advocates of harm reduction policies towards injecting drug use. Methods: We analysed key government reports, policy statements from public health bodies and non‐government organizations (e.g. cancer councils and medical organizations) on ENDS; submissions to an Australian parliamentary inquiry; media coverage of policy debates in medical journals; and the history of tobacco control policy in Australia and England. Key discourses about ENDS were identified for each country. These were compared across countries during a multi‐day face‐to‐face meeting, where consensus was reached on the key commonalities and divergences in historical approaches to nicotine policy. This paper focuses on England, as different policy responses were apparent in constituent countries of the United Kingdom, and Scotland in particular. Results: Policymakers in Australia and England differ markedly in the priority that they have given to using ENDS to promote smoking cessation or restricting smokers' access to prevent uptake among young people. In understanding the origins of these divergent responses, we identified the following key differences between the two countries' approaches to nicotine regulation: an influential scientific network that favoured nicotine harm reduction in the United Kingdom and the absence of such a network in Australia; the success of different types of health activism both in England and in Europe in opposing more restrictive policies; and the greater influence on policy in England of the field of illicit drug harm reduction. Conclusions: An understanding of the different policy responses to electronic nicotine delivery systems (ENDS) in England and Australia requires an appreciation of how actors within the different policy structures, scientific networks and activist organizations in each country and region have interpreted the evidence and the priority that policymakers have given to the competing goals of preventing adolescent uptake and encouraging smokers to use ENDS to quit smoking. [ABSTRACT FROM AUTHOR]

Aims: This paper presents updated prevalence estimates of awareness, ever‐use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing. Design, Setting, Participants and Measurements: A cross‐sectional analysis of adult (≥ 18 years) current smokers and ex‐smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013–17. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs), not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs), not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand; (3) less restrictive policies (LRPs), legal to be sold and marketed with regulations: England, the Netherlands, Republic of Korea, United States; and (4) no regulatory policies (NRPs), Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country‐specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily versus non‐daily). Findings NVP awareness and use were lowest in NRP countries. Generally, ever‐ and current use of NVPs were lower in MRP countries (ever‐use = 7.1–48.9%; current use = 0.3–3.5%) relative to LRP countries (ever‐use = 38.9–66.6%; current use = 5.5–17.2%) and RP countries (ever‐use = 10.0–62.4%; current use = 1.4–15.5%). NVP use was highest among high‐income countries, followed by upper–middle‐income countries, and then by lower–middle‐income countries. Conclusions: With a few exceptions, awareness and use of nicotine vaping products varied by the strength of national regulations governing nicotine vaping product sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in nicotine vaping products in these countries where smoking populations are predominantly poorer. The higher awareness and use of nicotine vaping products in high income countries with moderately (e.g. Canada, New Zealand) and less (e.g. England, United States) restrictive policies, is likely due to the greater availability and affordability of nicotine vaping products. [ABSTRACT FROM AUTHOR]

Background and aims Regulation of electronic cigarettes has moved to the top of the addiction policy agenda, as demonstrated by the recent focus across the United Kingdom on introducing age-of-sale restrictions. However, the views of those affected by such regulation remain largely unexplored. This paper presents the first detailed qualitative exploration of adolescents' perceptions of existing, and opinions about potential e-cigarette regulation. Methods Sixteen focus groups, including a total of 83 teenagers between the ages of 14 and 17 years, were conducted in deprived, mixed and affluent urban areas in Scotland and England between November 2014 and February 2015. Transcripts were imported into Nivivo 10, coded thematically and analysed. Results Participants critically considered existing evidence and competing interests in regulatory debates and demonstrated sophisticated understanding of the advantages and disadvantages of regulation. They overwhelmingly supported strong e-cigarette regulation and endorsed restrictions on sales to minors, marketing and e-cigarette use in public places. Concern about potential health harms of e-cigarette use and marketing increasing the acceptability of vaping and smoking led these adolescents to support regulation. Conclusions In focus group discussions, a sample of UK adolescents exposed to particular communications about e-cigarettes supported strict regulation of e-cigarettes, including banning sales to minors and use in indoor public areas. [ABSTRACT FROM AUTHOR]

Aim: To measure whether the prevalence of use and real‐world effectiveness of different smoking cessation aids has changed in England since the coronavirus disease 2019 (COVID‐19) pandemic. Design: Representative monthly cross‐sectional surveys, January 2015–June 2021. Setting: England. Participants: A total of 7300 adults (≥18 y) who had smoked within the previous 12 months and had made ≥1 quit attempt during that period. Measurements The independent variable was the timing of the COVID‐19 pandemic (pre‐pandemic [January 2015–February 2020] vs pandemic [April 2020–June 2021]). We analysed (i) the association between the pandemic period and self‐reported use (vs non‐use) during the most recent quit attempt of: prescription medication (nicotine replacement therapy [NRT]/varenicline/bupropion), NRT bought over‐the‐counter, e‐cigarettes, traditional behavioural support and traditional remote support (telephone support/written self‐help materials/websites) and (ii) the interaction between the pandemic period and use of these cessation aids on self‐reported abstinence from quit date to survey. Covariates included age, sex, social grade, level of cigarette addiction and characteristics related to the quit attempt. Findings After adjustment for secular trends, there was a significant increase from the pre‐pandemic to pandemic period in the prevalence of use of traditional remote support by past‐year smokers in a quit attempt (OR = 2.18; 95% CI, 1.42–3.33); specifically telephone support (OR = 7.16; 95% CI, 2.19–23.45) and websites (OR = 2.39; 95% CI, 1.41–4.08). There was also an increase in the prevalence of use of prescription medication (OR = 1.47; 95% CI, 1.08–2.00); specifically varenicline (OR = 1.66; 95% CI, 1.09–2.52). There were no significant changes in prevalence of use of other cessation aids after adjustment for secular trends. People who reported using prescription medication (OR = 1.41; 95% CI, 1.09–1.84) and e‐cigarettes (OR = 1.87; 95% CI, 1.62–2.16) had greater odds of reporting abstinence than people who did not. There were no significant interactions between the pandemic period and use of any cessation aid on abstinence, after adjustment for covariates and use of the other aids, although data were insensitive to distinguish no change from meaningful modest (OR = 1.34) effects (Bayes factors 0.72–1.98). Conclusions: In England, the COVID‐19 pandemic was associated with an increase in use of remote support for smoking cessation and varenicline by smokers in a quit attempt up to June 2021. The data were inconclusive regarding an association between the pandemic and changes in the real‐world effectiveness of popular smoking cessation aids. [ABSTRACT FROM AUTHOR]

Aims: To assess how changes in the prevalence of e‐cigarette use among young adults have been associated with changes in the uptake of smoking in England between 2007 and 2018. Design Time–series analysis of population trends with autoregressive integrated moving average with exogeneous input (ARIMAX models). Setting: England. Participants: Data were aggregated quarterly on young adults aged 16–24 years (n = 37 105) taking part in the Smoking Toolkit Study. Measures: In the primary analysis, prevalence of e‐cigarette use was used to predict prevalence of ever regular smoking among those aged 16–24. Sensitivity analyses stratified the sample into those aged 16–17 and 18–24. Bayes' factors and robustness regions were calculated for non‐significant findings [effect size beta coefficient (B) = 3.1]. Findings There was evidence for no association between the prevalence of e‐cigarette use and ever regular smoking among those aged 16–24 [B = –0.015, 95% confidence interval (CI) = –0.046 to 0.016; P = 0.341; Bayes factor (BF) = 0.002]. Evidence for no association was also found in the stratified analysis among those aged 16–17 (B = 0.070, 95% CI –0.014 to 0.155, P = 0.102; BF = 0.015) and 18–24 (B = –0.021, 95% CI –0.053 to 0.011; P = 0.205; BF = 0.003). These findings were able to rule out percentage point increases or decreases in ever regular smoking prevalence greater than 0.31% or less than −0.03% for 16–17‐year‐olds and 0.01 or −0.08% for 18–24‐year‐olds for every 1%‐point increase in e‐cigarette prevalence. Conclusion: Prevalence of e‐cigarette use among the youth population in England does not appear to be associated with substantial increases or decreases in the prevalence of smoking uptake. Small associations cannot be ruled out. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to examine how the proportion of dual users of cigarettes and e-cigarettes who use e-cigarettes in situations where smoking is not permitted has changed since e-cigarettes became popular in England, and to characterize those who do so.Methods: Data were from 5081 adults in England who reported current smoking and current use of e-cigarettes ('dual users') participating in a nationally-representative monthly survey between April 2011 and February 2020. We modeled quarterly changes in prevalence of e-cigarette use in situations where smoking is not permitted and assessed multivariable associations with sociodemographic and smoking characteristics.Results: Between 2011 and 2020, prevalence of e-cigarette use in situations where smoking is not permitted followed a positive cubic trend, with a decelerating increase from an estimated 52.5% of dual users in Q2-2011 to 72.7% in Q3-2014, followed by a small decline to 67.5% in 2018, and subsequent increase to 74.0% in 2020. Odds were higher among those who were from more disadvantaged social grades, reported stronger smoking urges, or had made a past-year quit attempt, and lower among those who were aged at least 65 years (vs. 16-24 years), from the south (vs. north) of England, reported currently cutting down on their cigarette consumption or currently using nicotine replacement therapy.Conclusions: In England, use of e-cigarettes in situations where smoking is not permitted is common among dual cigarette and e-cigarette users, has increased nonlinearly since 2011, and is particularly prevalent among those who are younger, disadvantaged, more addicted, have recently failed to quit, and are not attempting to cut down.Implications: The ability to use nicotine in smoke-free settings appears to be an important part of the appeal of e-cigarettes. It is possible that if e-cigarette use was prohibited in public places, smokers may be deterred from using e-cigarettes alongside combustible tobacco, which could undermine quitting. Our results suggest disadvantaged and more addicted smokers would be disproportionately affected, suggesting such restrictions may contribute to inequalities in smoking and associated health outcomes. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background and aims: Association of electronic cigarette use and subsequent smoking has received considerable attention, although age of first use has not. This study tested differences in regular (e‐cigarettes, cigarettes) and ever (cigarettes) use between e‐cigarette user groups: early versus never users, late versus never users, early versus late users and effects of controlling for covariates. Design Prospective study with 12‐ and 24‐month follow‐up of e‐cigarette/cigarette ever/regular use with data from an intervention. Setting: Forty‐five schools in England (Staffordshire and Yorkshire). Participants: Never smokers (3289 13–14‐year‐olds) who were part of a cluster randomized controlled trial. Measurements The sample was divided into groups of e‐cigarette users: early users (at 13–14 years), late users (at 14–15 years) and never users (at 13–14 and 14–15 years). Dependent variables were self‐reported regular e‐cigarette and cigarette use and ever cigarette use at 15–16 years. Covariates were assessed. Findings Early and late users compared with never users were significantly more likely to be regular e‐cigarette users [early: odds ratio (OR) = 9.42, 95% confidence interval (CI) = 5.38, 16.49, P < 0.001; late: OR = 6.89, 95% CI = 4.11, 11.54, P < 0.001], ever cigarette users (early: OR = 7.96, 95% CI = 6.02, 10.53, P < 0.001; late: OR = 5.13, 95% CI = 3.85, 6.84, P < 0.001) and regular cigarette users (early: OR = 7.80, 95% CI = 3.99, 15.27, P < 0.001; late: OR = 4.34, 95% CI = 1.93, 9.77, P < 0.001) at age 15–16 years. Late users compared with early users had significantly lower rates of ever use of cigarettes at 15–16 years (OR = 0.48, 95% CI = 0.35, 0.66, P < 0.001), although this difference was non‐significant at 12 months after first use of e‐cigarettes (OR = 0.89, 95% CI = 0.64, 1.25, P = 0.498). Controlling for covariates did not change the findings. Conclusions: Adolescents in England who report using e‐cigarettes at age 13–14 years have higher rates of subsequently initiating cigarette use than adolescents who report using e‐cigarettes at age 14–15 years, a difference that may be attributable to a longer period of time to initiate cigarette use in former group. [ABSTRACT FROM AUTHOR]

Objective: To estimate prevalence of vaping in pregnancy. Compare characteristics and attitudes between exclusive smokers and vapers, and between exclusive vapers and dual users (smoke and vape). Design: Cross‐sectional survey. Setting: Hospitals across England and Scotland. Population: Pregnant women attending antenatal clinics in 2017. Methods: Women at 8–24 weeks' gestation completed screening questions about their smoking and vaping. Current or recent ex‐smokers and/or vapers completed a full detailed survey about vaping and smoking. Main outcome measures: The prevalence of vaping, characteristics and attitudes of women who vape and/or smoke. Results: Of 3360 pregnant women who completed screening questions, 515 (15.3%, 95% CI 14.1–16.6) were exclusive smokers, 44 (1.3%, 95% CI 1.0–1.8) exclusive vapers and 118 (3.5%, 95% CI 2.9–4.2) dual users. In total, 867 (25.8%) women completed the full survey; compared with smokers (n = 434), vapers (n = 140) were more likely to hold higher educational qualifications (odds ratio [OR) 1.51, 95% CI 1.01–2.25). Compared with exclusive vapers (n = 33), dual users (n = 107) were younger (OR 0.91 95% CI 0.85–0.98) and less likely to hold high qualifications (OR 0.43, 95% CI 0.20–0.96). Compared with smokers, dual users were more likely to be planning to quit smoking (OR 2.27, 95% CI 1.24–4.18). Compared with smokers, vapers were more likely to think vaping was safer than smoking (78.6% versus 36.4%). Conclusions: One in 20 pregnant women report vaping, and most also smoke. Dual users are more motivated towards stopping smoking than smokers. Where women have tried but cannot stop smoking, clinicians could encourage them to consider vaping for smoking cessation. Tweetable extract: One in 20 women report vaping during pregnancy but of those that do vape, most also smoke, despite having intentions to quit. Tweetable extract: One in 20 women report vaping during pregnancy but, of those that do vape, most also smoke, despite having intentions to quit. [ABSTRACT FROM AUTHOR]

Background: There is a decreasing trend in the proportion of individuals who perceive e-cigarettes to be less harmful than conventional cigarettes across the UK, Europe and the US. It is important to assess whether this may influence the use of e-cigarettes. We aimed to estimate, using a time series approach, whether changes in harm perceptions among current tobacco smokers have been associated with changes in the prevalence of e-cigarette use in England, with and without stratification by age, sex and social grade.Methods: Respondents were from the Smoking Toolkit Study, which involves monthly cross-sectional household surveys of individuals aged 16+ years in England. Data were aggregated monthly on ~ 300 current tobacco smokers between 2014 and 2019. The outcome variable was the prevalence of e-cigarette use. The explanatory variable was the proportion of smokers who endorsed the belief that e-cigarettes are less harmful than combustible cigarettes. Covariates were cigarette (vs. non-cigarette combustible) current smoking prevalence, past-year quit attempt prevalence and national smoking mass media expenditure. Unadjusted and adjusted autoregressive integrated moving average with exogeneous variables (ARIMAX) models were fitted.Results: For every 1% decrease in the mean prevalence of current tobacco smokers who endorsed the belief that e-cigarettes are less harmful than combustible cigarettes, the mean prevalence of e-cigarette use decreased by 0.48% (βadj = 0.48, 95% CI = 0.25-0.71, p < .001). Marginal age and sex differences were observed, whereby significant associations were observed in older (but not in young) adults and in men (but not in women). No differences by social grade were detected.Conclusions: Between 2014 and 2019 in England, at the population level, monthly changes in the prevalence of accurate harm perceptions among current tobacco smokers were strongly associated with changes in e-cigarette use. [ABSTRACT FROM AUTHOR]

Aims: To provide up‐to‐date estimates of how changes in the prevalence of electronic cigarette (e‐cigarette) use in England have been associated with changes in smoking cessation activities and daily cigarette consumption among smokers in England. Design Time–series analysis of population trends. Setting: England. Participants: Participants came from the Smoking Toolkit Study, which involves repeated, cross‐sectional household surveys of individuals aged 16 years and older in England. Data were aggregated on approximately 1200 past‐year smokers each quarter (total n = 50 498) between 2007 and 2017. Measurements Prevalence of e‐cigarette use in current smokers was used to predict (a) prevalence of quit attempts among last‐year smokers, (b) overall quit rates among last‐year smokers and (c) mean cigarette consumption per day among current smokers. Prevalence of e‐cigarette use during a quit attempt among last‐year smokers was used to predict (a) quit success rate among last‐year smokers and (b) overall quit rates among last‐year smokers. Findings Overall quit rates increased by 0.054% [95% confidence interval (CI) = 0.032–0.076, P < 0.001] and 0.050% (95% CI = 0.031–0.069, P < 0.001) respectively for every 1% increase in the prevalence of e‐cigarette use by smokers and e‐cigarette use during a quit attempt. Quit success rates increased by 0.060% (95% CI = 0.043–0.078, P < 0.001) for every 1% increase in the prevalence of e‐cigarette use during a quit attempt. No clear evidence was found for an association between e‐cigarette use and either prevalence of quit attempt (BAdj = 0.011, 95% CI = −0.046 to 0.069, P = 0.698) or cigarette consumption (BAdj = 0.019, 95% CI = −0.043 to 0.082, P = 0.542). Conclusion: Changes in prevalence of e‐cigarette use in England have been positively associated with the overall quit rates and quit success rates but not clearly associated with the prevalence of quit attempts and mean cigarette consumption. [ABSTRACT FROM AUTHOR]

Aims: At a time of declining smoking prevalence in England, it is useful to document any changes in the characteristics of smokers. This has implications for targeting tobacco control policies and interventions. This study compared the characteristics of smokers from 2008 to 2017 to assess changes in smoking and quitting patterns and socio‐demographic profile. Design and setting Analysis of annual trends in results from repeated cross‐sectional surveys of representative samples of the population in England from 2008 to 2017. Participants: The study included 208 813 adults aged 16+. Measurements Information was gathered on age, sex, social grade and region, cigarette consumption, cigarette dependence as measured by time to first cigarette of the day, daily smoking, smoking roll‐your‐own cigarettes, attempts to cut down, use of an e‐cigarette or nicotine replacement therapy, attempts to cut down or quit, use of support in quit attempts and whether the quit attempt was abrupt. Findings During the period, mean daily cigarette consumption [B = –0.30, 95% confidence interval (CI) = –0.33 to −0.27] and the time to first cigarette score decreased (B = –0.03, 95% CI = –0.03 to −0.02). The proportion of smokers attempting to cut down or quit decreased (odds ratio (OR) range = 0.96–0.97, 95% CI range = 0.95–0.97). Use of behavioural support [odds ratio (OR) = 0.89, 95% CI = 0.86–0.92] or no support decreased (OR = 0.98, 95% CI = 0.96–0.99), while use of pharmacological support, including e‐cigarettes, increased (OR = 1.04, 95% CI = 1.02–1.05). There was no significant change in the difference in social grade between smokers and non‐smokers comparing 2008 with 2017. Changes in smoking and quitting behaviour were independent of changes in socio‐demographic characteristics. Conclusions: Between 2008 and 2017 in England, smokers appear to have become less dependent on cigarettes but less likely to try to quit or cut down. Of those who tried to quit, fewer used behavioural support and more used pharmacological support. The proportion from more disadvantaged backgrounds did not change significantly. [ABSTRACT FROM AUTHOR]

Aims: To quantify associations between the success of smoking quit attempts and factors that have varied throughout 2007–2018 at a population level. Design time series analysis using Autoregressive Integrated Moving Average with Exogeneous Input (ARIMAX) modelling. Setting and Participants: Data were aggregated from 54 847 past‐year smokers taking part in the Smoking Toolkit Study which involves monthly repeated cross‐sectional household surveys of individuals aged 16+ in England. Measurements The input series were: (1) attempts at smoking reduction using (a) e‐cigarettes and (b) nicotine replacement therapy (NRT); (2) use during a quit attempt of (a) e‐cigarettes, (b) NRT over‐the‐counter, (c) medication on prescription and (d) face‐to‐face behavioural support; (3) use of roll‐your‐own tobacco; (4) prevalence of (a) smoking and (b) non‐daily smoking; (5) tobacco control mass media expenditure; (6) expenditure on smoking; (7) smoker characteristics in the form of (a) high motivation to quit, (b) average age, (c) socio‐economic status and (d) cigarette consumption; (8) implementation of tobacco control policies; and (9) quit attempt rate. Findings The licensing of NRT for harm reduction was associated with a 0.641% [95% confidence interval (CI) = 0.073–1.209, P = 0.027] increase in the mean point prevalence of the success rate of quit attempts. For every 1% increase in the mean point prevalence of e‐cigarette use and use of prescription medication during a quit attempt, the mean point prevalence of successful quit attempts increased by 0.106% (95% CI = 0.011–0.201, P = 0.029) and 0.143% (95% CI = 0.009–0.279, P = 0.038), respectively. For every 1% increase in the mean expenditure on tobacco control mass media, the mean point prevalence of successful quit attempts increased by 0.046% (95% CI = 0.001–0.092, P = 0.046). Other associations were not statistically significant. Conclusion: In England between 2007 and 2018, licensing of nicotine replacement therapy for use in harm reduction, greater use of e‐cigarettes and prescription medications during a quit attempt and higher expenditure on tobacco control mass media were all associated with higher success rates of quit attempts. [ABSTRACT FROM AUTHOR]

Background and Aims: The expense associated with using non‐combustible nicotine products as an alternative to smoking may deter smoking reduction or cessation. This study aimed to estimate (i) how much adults in England spend each week on smoking and alternative nicotine products and (ii) the potential cost saving that could be achieved by switching from smoking to using an alternative nicotine delivery product. Design and Setting: Data came from September to November 2018 waves of the Smoking Toolkit Study, a series of national household surveys of the adult population in England. Participants: A total of 859 adults (aged ≥ 16 years) who reported current smoking or current use of an alternative nicotine product. Measurements Participants reported their average weekly expenditure on smoking and alternative nicotine products [nicotine replacement therapy (NRT) or e‐cigarettes]. Findings Current smokers who did not use any alternative nicotine delivery products (n = 602) reported spending on average £23.09 [95% confidence interval (CI) = £21.64–24.54] on smoking each week. Ex‐smokers who used alternative nicotine products (n = 91) reported spending on average £8.59 (95% CI = £6.80–10.39) on these products each week; £8.03 (95% CI = £6.03–10.03) on e‐cigarettes and £10.05 (95% CI = £5.62–14.47) on NRT. People who both smoked and used alternative nicotine products (dual users, n = 166) spent on average £24.54 (95% CI = £21.78–27.29) on smoking and £7.49 (95% CI = £6.00–8.99) on alternative nicotine products each week. Expenditure on smoking was higher among heavier, more addicted smokers and lower among those with routine/manual occupations, non‐daily smokers and roll‐your‐own tobacco users. Expenditure on e‐cigarettes was higher among men, users from central and southern versus northern England and smokers who had tried to quit in the past year, and lower among current smokers. Expenditure on NRT was lower among roll‐your‐own tobacco users. Conclusions: In England, expenditure among e‐cigarette and nicotine replacement therapy users is approximately one‐third of the expenditure of smokers. The average smoker may save an estimated £15.06 per week by switching completely to e‐cigarettes or £13.04 per week by switching to nicotine replacement therapy, although this is likely to differ according to individual usage patterns. [ABSTRACT FROM AUTHOR]

Aims: To examine whether norms towards nicotine vaping product (NVP) use varied between Australia, Canada, England and the United States and by socio‐demographics, smoking and NVP status. Design Cross‐sectional data from the 2016 ITC Four Country Smoking and Vaping Survey. Setting: Four countries with distinct regulatory policies relating to the sale and advertising of NVPs: Australia (most restrictive), Canada (restrictive), England and the United States (least restrictive). Participants: A total of 10900 adult (age 18+) current smokers, former smokers, or at least weekly NVP users. Respondents were from Australia (n = 1366), Canada (n = 3309), England (n = 3835) and the United States (n = 2390). Measurements Questions permitted the categorization of respondents as current smokers, former smokers, NVP users and socio‐demographic categories (sex, age, country, ethnicity, income and education). Further questions were asked regarding the frequency of exposure to NVPs in public, whether they had a partner or close friends who vaped and whether they believed society or those considered important to them approved of NVPs. Findings Adjusting for relevant covariates, compared with Australian respondents, those in England, Canada and the United States were more likely to report frequent exposure to NVPs in public (83.1%, 57.3% and 48.3%, respectively, compared to 19.8% in Australia; P < 0.0001), having a partner who vaped (13.8%, 7.1% and 7.7%, respectively, compared to 2.1% in Australia; P < 0.0001) and having close friend(s) who vaped (31.7%, 25.3%, 20.9%, respectively, compared to 10.0% in Australia; P < 0.0001). Compared with Australian respondents, respondents from England were more likely to report that society (27.6% compared to 12.3% in Australia; P < 0.0001) and people important to them approved of NVP use (28.9% compared to 14.3% in Australia; P < 0.0001). Conclusions: Norms towards nicotine vaping product (NVP) use appear to vary among countries with different regulatory contexts regarding sales and advertising. [ABSTRACT FROM AUTHOR]

Background and Aims: Debate exists about whether health professionals (HPs) should advise smokers to use nicotine vaping products (NVPs) to quit smoking. The objectives were to examine in four countries: (1) the prevalence of HP discussions and recommendations to use an NVP; (2) who initiated NVP discussions; (3) the type of HP advice received about NVPs; and (4) smoker's characteristics related to receiving advice about NVPs. Design Cross‐sectional study using multivariable logistic regression analyses on weighted data from the 2016 ITC Four Country Smoking and Vaping Survey (ITC 4CV1). Setting: Four countries with varying regulations governing the sale and marketing of NVPs: 'most restrictive' (Australia), 'restrictive' (Canada) or 'less restrictive' (England and United States). Participants: A total of 6615 adult smokers who reported having visited an HP in the last year (drawn from the total sample of 12 294 4CV1 respondents, of whom 9398 reported smoking cigarettes daily or weekly). Respondents were from the United States (n = 1518), England (n = 2116), Australia (n = 1046), and Canada (n = 1935). Measurements Participants' survey responses indicated if they were current daily or weekly smokers and had visited an HP in the past year. Among those participants, further questions asked participants to report (1) whether NVPs were discussed, (2) who raised the topic, (3) advice received on use of NVPs and (4) advice received on quitting smoking. Findings Among the 6615 smokers who visited an HP in the last year, 6.8% reported discussing NVPs with an HP and 2.1% of smokers were encouraged to use an NVP (36.1% of those who had a discussion). Compared with Australia (4.3%), discussing NVPs with an HP was more likely in the United States [8.8%, odds ratio (OR) = 2.15, 95% confidence interval (CI) = 1.41–3.29] and Canada (7.8%, OR = 1.87, 95% CI = 1.26–2.78). Smokers in Australia were less likely to discuss NVPs than smokers in England (6.2%), although this was not statistically significant (OR = 1.47, 95% CI = 0.98–2.20). Overall, the prevalence of HPs recommending NVPs was three times more likely in the United States than in Australia (OR = 3.07, 95% CI = 1.45–6.47), and twice as likely in Canada (OR = 2.28, 95% CI = 1.06–4.87) than in Australia. Australia and England did not differ (OR = 1.76, 95% CI = 0.83–3.74). Just over half (54%) of respondents brought up NVPs themselves; there were no significant differences among countries. Conclusions: Discussions in Australia, Canada, England, and the United States between smokers and health professionals about nicotine vaping products appear to be infrequent, regardless of the regulatory environment. A low percentage of health professionals recommended vaping products. This was particularly evident in Australia, which has the most restrictive regulatory environment of the four countries studied. [ABSTRACT FROM AUTHOR]

Background and Aims: Understanding whether and how far smokers' characteristics influence the effectiveness of treatment may be important for tailoring recommendations on cessation aids to those most likely to help the user achieve abstinence. This study aimed to estimate the effectiveness of commonly used smoking cessation aids and test whether their effectiveness differs according to cigarette addiction, socio‐economic status, age or sex. Design Correlational design using cross‐sectional survey data collected monthly between 2006 and 2018. Setting: England. Participants: A total of 18 929 adults (aged ≥ 16 years, 52.0% female) who had smoked within the previous 12 months and had made at least one quit attempt during that period. Measurements The outcome was self‐reported abstinence from quit date to survey. Independent variables were self‐reported use during the most recent quit attempt of: prescription nicotine replacement therapy (NRT), NRT over‐the‐counter, varenicline, bupropion, e‐cigarettes, face‐to‐face behavioural support, telephone support, written self‐help materials, websites and hypnotherapy. Moderators were cigarette addiction, social grade, age and sex. Findings After adjustment for covariates and use of other cessation aids, users of e‐cigarettes [odds ratio (OR) = 1.95, 95% confidence interval (CI) = 1.69–2.24] and varenicline (OR = 1.82, 95% CI = 1.51–2.21) had significantly higher odds of reporting abstinence than those who did not report use of these cessation aids. Use of prescription NRT was associated with increased abstinence in older (≥ 45 years) (OR = 1.58, 95% CI = 1.25–2.00) but not younger (< 45 years) smokers (OR = 1.09, 95% CI = 0.85–1.42). Use of websites was associated with increased abstinence in smokers from lower (OR = 2.20, 95% CI = 1.22–3.98) but not higher social grades (OR = 0.74, 95% CI = 0.40–1.38). There was little evidence of benefits of using other cessation aids. Conclusions: Use of e‐cigarettes and varenicline are associated with higher abstinence rates following a quit attempt in England. Use of prescription of nicotine replacement therapy is also associated with higher abstinence rates, but only in older smokers, and use of websites only in smokers from lower socio‐economic status. [ABSTRACT FROM AUTHOR]

Background: The estimated number of cigarette smokers in the world is 1.3 billion, expected to rise to 1.7 billion by 2025, with 10 million smokers living in the U.K. Smoking is the leading, preventable death-cause worldwide, being responsible for almost 650,000 deaths in the E.U. annually. A combination of pharmacological interventions, including nicotine replacement therapy, bupropion and varenicline, and behavioural support is the most effective approach to smoking cessation. However, even the best methods have high relapse rates of approximately 75% within 6 months. Electronic (or "e-") cigarettes use battery power to disperse a solution that usually contains propylene glycol or glycerine, water, flavouring and nicotine. E-cigarettes have become the most popular smoking cessation aid in England, however, information on their effects on cardiovascular function is limited and contradictory. As e-cigarettes are not solely nicotine-based products, existing research exploring the effects of nicotine on the cardio-vasculature provides only limited information, while their extensive uptake urges the need of evidence to inform the general public, smokers and policy-makers.Methods: This is a pragmatic, 3-group, randomised, assessor-blinded, single-centre trial exploring the cardiovascular physiological effects of the use of e-cigarettes (nicotine-free and nicotine-inclusive, assessed separately) combined with behavioural support as a smoking cessation method in comparison to the combination of NRT and behavioural support. The primary outcome will be macro-vascular function, determined by a Flow Mediated Dilatation ultrasound assessment, 6 months following participants' "quit date".Discussion: Participants will be assessed at baseline, 3 days following their self-determined "quit date", at intervention end (3 months) and 6 months following their "quite date". Findings are expected to give an indication of the cardiovascular effects of e-cigarettes both in the short- and in the medium-term period, informing the general public, policy holders and researchers, helping to define the future role of e-cigarettes as a smoking cessation aid.Trial Registration: Clinicaltrials.gov NCT03061253 . Registered 17th February 2017. [ABSTRACT FROM AUTHOR]

Background and Aims Electronic cigarettes (e-cigarettes) are rapidly increasing in popularity. Two randomized controlled trials have suggested that e-cigarettes can aid smoking cessation, but there are many factors that could influence their real-world effectiveness. This study aimed to assess, using an established methodology, the effectiveness of e-cigarettes when used to aid smoking cessation compared with nicotine replacement therapy (NRT) bought over-the- counter and with unaided quitting in the general population. Design and Setting A large cross-sectional survey of a representative sample of the English population. Participants The study included 5863 adults who had smoked within the previous 12 months and made at least one quit attempt during that period with either an e-cigarette only (n = 464), NRT bought over-the-counter only (n = 1922) or no aid in their most recent quit attempt (n = 3477). Measurements The primary outcome was self-reported abstinence up to the time of the survey, adjusted for key potential confounders including nicotine dependence. Findings E-cigarette users were more likely to report abstinence than either those who used NRT bought over-the-counter [odds ratio (OR) = 2.23, 95% confidence interval (CI) = 1.70–2.93, 20.0 versus 10.1%] or no aid (OR = 1.38, 95% CI = 1.08–1.76, 20.0 versus 15.4%). The adjusted odds of non-smoking in users of e-cigarettes were 1.63 (95% CI = 1.17–2.27) times higher compared with users of NRT bought over-the-counter and 1.61 (95% CI = 1.19–2.18) times higher compared with those using no aid. Conclusions Among smokers who have attempted to stop without professional support, those who use e-cigarettes are more likely to report continued abstinence than those who used a licensed NRT product bought over-the-counter or no aid to cessation. This difference persists after adjusting for a range of smoker characteristics such as nicotine dependence. [ABSTRACT FROM AUTHOR]

Background: E-cigarettes are the most popular aid to smoking cessation attempts in England and the USA. This research examined associations between e-cigarette device characteristics and patterns of use, tobacco-smoking relapse, and smoking abstinence. Methods: A convenience sample of 371 participants with experience of vaping, and tobacco-smoking abstinence and/or relapse completed an online cross-sectional survey about e-cigarettes. Factors associated with smoking relapse were examined using multiple linear and logistic regression models. Results: Most participants were self-reported long-term abstinent smokers (86.3%) intending to continue vaping. Most initiated e-cigarette use with a vape pen (45.8%) or cig-a-like (38.7%) before moving onto a tank device (89%). Due to missing data, managed through pairwise deletion, only around 70 participants were included in some of the main analyses. Those using a tank or vape pen appeared less likely to relapse than those using a cig-a-like (tank vs. cig-a-like OR = 0.06, 95% CI 0.01–0.64, p = 0.019). There was an inverse association between starting self-reported e-cigarette liquid nicotine concentration and relapse, interacting with device type (OR = 0.79, 95% CI 0.63–0.99, p = 0.047), suggesting that risk of relapse may have been greater if starting with a low e-cigarette liquid nicotine concentration and/or cig-a-like device. Participants reported moving from tobacco-flavored cig-a-likes to fruit/sweet/food flavors with tank devices. Conclusions: Knowledge of how people have successfully maintained tobacco-smoking abstinence using vaping could help other tobacco smokers wishing to quit tobacco smoking through vaping. [ABSTRACT FROM AUTHOR]