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This study will examine how the prevalence of smoking, vaping and inhaled nicotine use has changed since the growth in disposable e-cigarette use in Great Britain. Full details are available in the pre-registered protocol and analysis plan.

Using data from the Health Survey for England 2019, we aim to estimate, among people who exclusively smoke, exclusively vape, and dual use, the percentage that report having recently used their nicotine products inside (anywhere inside, inside the home, inside the car, and/or inside other places). In exclusive users, we will also examine how the prevalence of inside vaping and smoking varies by age, sex, housing tenure, social grade, presence of a child or adult in the home, smoking and vaping history, and nicotine dependence.

This survey was used as part of the evaluation of a smoking cessation/support health marketing educational campaign about the relative safety of e-cigarettes. This campaign ran in 2017 and 2018 in Greater Manchester. Publication of the findings from this evaluation, can be found: https://academic.oup.com/ntr/article/22/7/1148/5677516. This survey has been reduced to focus and share the metrics used to understand smoking behaviours, e-cigarette use and attitudes and perceptions of e-cigarettes. Commercially sensitive metrics related to the campaign themselves have been removed.

Early in the COVID-19 pandemic, there was a strong a priori assumption that smoking was an increased risk factor for disease severity owing to a high incidence of respiratory illness and pre-existing poor lung function in long-term smokers (1,2). However, results of a living systematic meta-analysis indicate that current smokers appear to be at reduced risk of COVID-19 infection relative to non-smokers, and there is inconclusive evidence that smokers who are infected are at increased risk of more severe disease (3). Former smokers appear to be at increased risk of severe disease and mortality from COVID-19 (3). Nonetheless, the pandemic has triggered some smokers to consider improving their health; we found that rates of smoking cessation were higher post March 2020 lockdown compared with the pre-pandemic period in England (4). Evidence from the UK also shows that concern around infection is more common in current compared with never smokers, and smokers report being less able to enact personal protective behaviours (5). In the UK, several health agencies recognised this as a ‘tobacco teachable moment’, and there was a well a publicised ‘Quit for Covid’ public health campaign (6). Even within the context of the pandemic, smoking continues to be a public health priority. This is salient in England, where there is less than a decade to achieve the public health goal of being smoke free by 2030 (defined as a smoking prevalence of 10 cigarettes per day). Since the data presented above (5,9) were collected, there have been several important developments. Firstly, England has experienced two more lockdowns. Second, the absolute death and population infection rate has risen. These longer-term effects of the pandemic may have continued to impact people’s decisions to change their behaviour, especially modifying behaviours like smoking. Third, there has been an increase in access to and uptake of COVID-19 testing in England, and thus, the accuracy of whether people have had COVID-19 in self-reports is now likely to be greater than early in the history of the pandemic. Assessing the association of COVID-19 infection status on current and future changes to smoking with greater accuracy is now possible.

This study will examine changes over time (2017-2020) in (a) exposure to negative news stories about e-cigarettes, and (b) harm perceptions of e-cigarettes, and whether any changes over time vary across countries (Canada, US, England). This study will also examine whether exposure to negative news stories about e-cigarettes is associated with harm perceptions of e-cigarettes.

Using a nationally representative repeat cross-sectional survey in England, this study aimed to i) assess inequalities in smoking and quitting behaviour among all adults in recent years by children in the household and ii) explore trends in smoking prevalence between 2013 and 2019 among adults with and without children in the household by SEP.

The research aims, analysis plan and priors for this study were selected before data analysis. Details of these are available in the pre-analysis protocol and prior selection document.

The ongoing COVID-19 pandemic, caused by the SARS-CoV-2 virus, is placing an unprecedented burden on healthcare and social systems in the UK and globally: with community transmission established in February 2020, COVID-19 has led to >9 million infections in the UK, with >140,000 premature deaths as of November 2021. At the start of the pandemic, many researchers and healthcare professionals hypothesised that tobacco smoking would be a risk factor for SARS-CoV-2 infection and subsequent disease progression. This was based on prior knowledge of biological, social, and behavioural factors that increase the risk of viral transmission. First, SARS­CoV­2 enters epithelial cells through the angiotensin-converting enzyme 2 (ACE­2) receptor, with evidence suggesting that gene expression and subsequent receptor levels are elevated in smokers, thus potentially putting smokers at higher risk of contracting SARS­CoV­2 if exposed to the virus. However, reduced receptor levels in smokers have also been reported. Second, both current and former smoking increase the risk of other respiratory viral and bacterial infections. Third, behavioural factors involved in smoking (e.g. regular hand-to-mouth movements) may increase SARS­CoV­2 infection through increased exposure and onward transmission once infected. Fourth, individuals from lower (compared with higher) socioeconomic position (SEP) groups are more likely to be smokers and are also more likely to live in overcrowded housing and/or be employed in occupations with increased viral exposure (e.g., supermarkets, warehouses, public transport). If smoking confers an increased risk of infection, this would further emphasise the need for public health efforts to support smoking cessation, with campaigns potentially leveraging motivation to quit to protect oneself and others from COVID-19. We aim to examine, in the nationally representative UK Office for National Statistics (ONS) COVID-19 Infection Survey, whether 1) current vs. never smoking is associated with reduced risk of a) testing positive for SARS-CoV-2; and b) SARS-CoV-2 seropositivity; 2) former vs. never smoking is associated with increased risk of a) testing positive for SARS-CoV-2; and b) SARS-CoV-2 seropositivity; 3) among nicotine users, current cigarette smoking vs. no cigarette smoking is associated with equivocal risk of a) testing positive for SARS-CoV-2; and b) SARS-CoV-2 seropositivity; 4) among former and never smokers, e-cigarette use vs. no e-cigarette is associated with reduced risk of a) testing positive for SARS-CoV-2; and b) SARS-CoV-2 seropositivity; 5) for the above questions, whether associations vary over the course of the pandemic; and 6) in those testing positive for SARS-CoV-2, current smoking/nicotine use is associated with a) greater mean PCR cycle threshold values; and b) a lower number of self-reported symptoms.

Preregistration of protocol (before analysis) of a study that willl use data from a nationally representative population survey in England over the last seven years to describe smoking prevalence rates among adults who self-report alcohol consumption at levels indicating that they are at risk of alcohol dependence, and characterise smoking and smoking cessation characteristics among past-year smokers who are at risk of alcohol dependence. We will further compare smoking and smoking cessation characteristics among past-year smokers who are at risk of alcohol dependence with past-year smokers who are drinking alcohol below this threshold.

Perceived harm of e-cigarettes compared with cigarettes following the US outbreak of vaping-associated lung injury.

Since 2020 governments worldwide have imposed varying levels of restrictions to limit the widespread transmission of the SARS-Cov-2 virus and the resulting burden of morbidity and mortality caused by COVID-19 (1). To deal with exponentially growing numbers of seriously ill COVID-19 patients while protecting staff and other patients, health care in England underwent considerable changes. These included redirecting hospital staff and resources, postponement or remote delivery of outpatient services and the suspension of in-person primary care in the community (2). Even during periods without COVID-19 related restrictions, changes have occurred in GP service delivery, which have shifted towards online and telephone consultations (3). In England prior to the pandemic, there were substantial differences in rates of delivery of brief interventions (BI) for smoking and alcohol, with 48.3% of smokers having received a BI in the past year compared with 6.1% of higher-risk drinkers (4). It is important to understand how the COVID-19 pandemic has affected the receipt of brief interventions for smoking and alcohol, and whether certain priority groups have been differentially affected. Increasing and higher risk alcohol consumption (defined as a score greater than or equal to eight on the AUDIT (Alcohol Use Disorders Identification Test)) and tobacco smoking remain leading causes of preventable morbidity and mortality globally and within England (5). These behaviours and their associated harms are also patterned socioeconomically such that the burden falls disproportionately upon certain groups including those with lower incomes or less stable employment (6,7), and/or with diagnoses of mental health problems (8,9). For instance, 25% of adults working in routine and manual occupations in England smoke, compared with 10% of those in professional and managerial occupations (10). In 2014/15 smoking prevalence was estimated to be 28% among those with anxiety or depression, and 41% among those with serious mental illness (including psychosis, bipolar disorder, eating disorders and severe depression) (9). The estimate for the smoking prevalence in the general population during the same period was 19% (11). Socio-economic patterns of alcohol consumption are more complex. Despite people from more disadvantaged backgrounds being more likely to abstain from drinking and to drink less overall than those from more advantaged groups (12), alcohol-related morbidity and mortality is generally higher (13,14). Explanations for this ‘alcohol harm paradox’ are complex and often untested but may related to differences in the pattern (15) and context of drinking, disadvantage and upstream socio-political or commercial factors (16). It is possible that the widespread deterioration of mental health during the pandemic (17,18) has interacted negatively with smoking. Given that many smokers report smoking to alleviate stress and feelings of depression and anxiety (symptoms which themselves may be due to the experience of nicotine withdrawal), they may be less likely to quit or more likely to relapse if they perceive that their mental health will suffer in the absence of smoking (19). As with smoking, higher risk alcohol consumption is associated with mental health problems (8,20–22).During the period of pandemic restrictions alcohol consumption diverged with some reporting increased drinking (23,24) (possibly related to increased levels of stress (25–27)) and has been independently associated with poorer overall mental health in the UK (28,29). Finally, smoking and alcohol use are often not distinct behaviours. Smoking prevalence is considerably higher among drinkers compared with non-drinkers, and there is evidence of increasing smoking prevalence at increasing levels of alcohol use (30). The COVID-19 pandemic has had a varied impact on smoking and alcohol consumption and the use of evidence-based support. Increases in higher risk drinking among all adults and smoking prevalence among young adults were reported following the first COVID-19 lockdown in March 2020 (23,31). The same studies reported increases in smoking quit attempts, quit success and the use of remote support. Regarding alcohol, declines were found in the use of evidence-based support among higher risk drinkers, with no changes in the use of remote support. Moreover, increases in higher risk drinking were not equal among all adults, with greater increases among women and people from less advantaged occupational grades (31). These findings provide useful information on behaviours during the early stages of the pandemic, but more research is needed into behaviours over a longer period alongside successive waves of COVID infections and the related government and health system responses. National government guidance has recommended the use of screening and BIs to combat smoking and increasing and higher risk drinking among patients visiting UK primary care settings (32,33). BIs in primary care in the UK typically involve an initial screening step followed by delivery of structured feedback and advice or behaviour change counselling, and have been shown to be an effective tool to increase smoking cessation rates and reduce higher risk drinking (34–36). The National Institute for Health and Care Excellence) guidelines emphasise the importance of targeting priority groups - often those experiencing multiple disadvantages - who find smoking/alcohol cessation and/or reduction difficult. This emphasis appears to be reflected in evidence of greater receipt of BIs among priority socioeconomic groups in England; however, absolute intervention delivery rates for higher risk drinkers is low (4,37). It is not known whether the ongoing pandemic has affected the receipt of brief interventions for smoking and increasing and higher risk drinking in primary care, or if it has impacted inequalities in delivery among priority groups of smokers and drinkers compared with previous years (where approximately 50% of smokers and 10% of higher risk drinkers reported receiving advice to quit or cut down, respectively (4,38)). Due to changes in healthcare delivery and smoking and drinking behaviour the ongoing COVID-19 pandemic may have influenced reductions in the receipt of BIs. If so, it is important to understand whether this has disproportionately impacted those who are at greater risk of harm, such as those experiencing socioeconomic disadvantage and mental health problems. This study aims to examine changes in the receipt of BIs for smoking cessation and increasing and higher risk drinking following the onset of the COVID-19 pandemic in England compared with previous years and whether receipt was moderated by socio-economic or mental health status.