Trends in non-cigarette tobacco smoking in England: a population survey 2013-2023

BackgroundThe UK Government intends to implement a smokefree generation policy prohibiting the sale of all tobacco products to people born after 2008. National surveys provide comprehensive data on cigarette smoking, but little is known about patterns of non-cigarette tobacco smoking across key population groups. MethodsUsing data from a nationally-representative cross-sectional survey of adults ([≥]18y) in England, collected monthly between September-2013 and September-2023 (n=196,721), we estimated time trends in non-cigarette tobacco smoking prevalence, overall and by age, gender, occupational social grade, region, ethnicity, and vaping status. Interviews were conducted face-to-face until March-2020 and via telephone thereafter. ResultsFrom September-2013 to September-2023, there was a non-linear increase in non-cigarette tobacco smoking prevalence (from 0.36% to 1.68%; PR=4.72 [95%CI=3.43-6.48]). Prevalence was relatively stable up to February-2020 (at an average of 0.46%), then increased sharply at the start of the Covid-19 pandemic, to 0.90% [0.82-0.99%] in March-2020. This was followed by a steadier rise, peaking at 1.97% in May-2022, before falling slightly to 1.68% by September-2023. As a result, in 2022/23, one in ten smokers (10.8% [9.64-12.0%]) used non-cigarette tobacco. This rise was observed across all subgroups but was most pronounced among younger adults (e.g., reaching 3.21% of 18-year-olds vs. 1.09% of 65-year-olds). Prevalence was consistently higher among men (2.17% in September-2023 vs. 1.07% women) and current vapers (4.71% vs. 1.25% non-vapers). ConclusionsWhile exclusive use of non-cigarette combustible tobacco remains rare among adults in England, it increased at the start of the Covid-19 pandemic (at the same time as survey methods changed) but subsequently continued increasing steadily until May-2022. As of September-2023, there were [~]772,800 adult non-cigarette tobacco smokers in England; around five times more than a decade earlier. The rise in prevalence differed by age, with a more pronounced rise leading to higher prevalence among younger than older ages. What is already known on this topicThere is good evidence from nationally-representative population surveys on the prevalence and patterns of cigarette smoking in England. Less is known about use of other combustible tobacco products. What this study addsPrevalence of non-cigarette tobacco smoking has risen substantially since the start of the Covid-19 pandemic, particularly among younger adults. As a result, one in 10 smokers in England now does not smoke cigarettes at all but smokes some other form of combustible tobacco. How this study might affect research, practice or policyThe UK Government is planning to ban the sale of tobacco products to those born after 2008. The inclusion of non-cigarette combustible tobacco products under this policy is likely to be important for achieving the greatest reduction in youth uptake of tobacco smoking, as it would ensure young people who are unable to legally buy cigarettes do not buy other combustible tobacco products that are similarly harmful to health.