research on smoking

Tobacco smoking is one of the world’s largest health problems today.

By Hannah Ritchie and Max Roser

This article was first published in May 2013. The last revisions were done in November 2023.

See all our interactive charts on smoking ↓

Tobacco smoking is one of the world's largest health problems. Millions of people live in poor health because of it. Researchers estimate that every year around 8 million people die an early death due to smoking.

It has been a major health problem for many decades. For the entire 20th century, it is estimated that around 100 million people died prematurely because of smoking, most of them in rich countries. 1

The share of smokers among the world population is falling, and because smoking is such a large health problem today, this is one of the most positive developments in global health. It makes it possible for millions of people to live a longer and healthier life.

For a brief overview of the most important facts, see the following article:

Smoking: How large of a global problem is it? And how can we make progress against it?

Every year, around 8 million people die prematurely as a result of smoking. But there are things we can do to prevent this.

Other research and writing on smoking on Our World in Data:

In which countries do people smoke the most?

Who smokes more, men or women.

• Why is life expectancy in the US lower than in other rich countries?
• How do researchers estimate the death toll caused by each risk factor, whether it’s smoking, obesity, or air pollution?

Smoking is one of the leading risks for early death

Smoking is responsible for about 8 million premature deaths each year.

The two regularly updated studies on the global death toll from tobacco use – published by the World Health Organization and the Institute for Health Metrics and Evaluation – agree that around 8 million people die prematurely yearly.

The aggregate statistics refer to ‘tobacco use’ (rather than smoking alone) because other forms of consuming tobacco, such as chewing tobacco, also lead to premature deaths. The huge majority of deaths from tobacco use, however, are due to smoking. The death toll from smoking is very close to the total sum of deaths from tobacco use (higher than 99.9% in the case of the IHME estimates).

World Health Organization: More than 8 million die from tobacco use every year

The WHO estimates that more than 8 million people die prematurely yearly from tobacco use. This is the latest available WHO estimate as of November 2023. 2

More than 7 million of those deaths result from direct tobacco use. About 1.3 million are non-smokers who are dying because they are exposed to second-hand smoke.

IHME's Global Burden of Disease study: 8.7 million die from tobacco use every year

The IHME – in their annual Global Burden of Disease study – estimates that 8.7 million people die prematurely from tobacco use every year. As of November 2023, these are the latest estimates and refer to deaths in the year 2019. The references can be found in the footnote. 3

7.7 million of those deaths result from smoking, while 1.3 million are non-smokers who are dying because they are exposed to second-hand smoke. (An additional 56,000 people die annually from chewing tobacco.)

Most (71%) of those who die prematurely from smoking are men.

These estimates of the annual number of deaths attributed to a wide range of risk factors are shown in the interactive chart. This visualization is, by default, showing the global total, but can be explored for any country or region using the "change country" option. Smoking is a risk factor for several of the world's leading causes of death, including lung and other forms of cancer, heart disease, and respiratory diseases.

Smoking led to about 100 million premature deaths in the 20th-century

Tobacco smoking has been one of the world's largest health problems for decades. Over the course of the 20th century, it killed around 100 million people, most of them in today's rich countries. 1 The health burdens of smoking are now moving from high-income to low-to-middle-income countries; some estimates have suggested that one billion people could die from tobacco over the 21st century. 4

The global distribution of smoking deaths

In many countries, a high share of deaths is attributed to smoking.

In the map, we see the share of deaths attributed to direct smoking across the world. In many countries, this share is substantial.

Related – the share of deaths from secondhand smoking : This map shows the share of premature deaths attributed to secondhand smoke across the world.

Death rates from smoking are highest across Asia and Eastern Europe

In the interactive map, we show death rates from tobacco smoking across the world. Death rates measure the number of premature deaths from smoking per 100,000 people in a given country or region.

We see large differences in death rates across the world. Rates tend to be highest across Asia and Eastern Europe, where figures are often over 100, and in some cases, over 150 deaths per 100,000 people.

Death rates are much lower across some of the lowest-income countries in the world, where very few people smoke.

Related – the number of deaths from smoking. This map shows the annual number of deaths from tobacco smoking across the world.

Most deaths from smoking occur in older populations

When we look at the breakdown of deaths from smoking by age, we see that it is mainly older populations that are affected.

In the visualizations, we show the death rates from smoking by age bracket and the share of annual deaths that occur in each age group.

Here, we see that death rates from smoking are much higher in people older than 70 years old, followed by those aged 50 to 69.

How has the death toll due to smoking changed over time?

Death rates from smoking have declined in most countries.

Globally, smoking-related death rates have fallen .

But there are differences across countries. Where in the world are death rates falling or rising?

In the scatterplot, we see the comparison of smoking death rates in 1990 (shown on the y-axis) versus the death rate in the latest data (on the x-axis). The grey line is the line of parity: countries that lie along this line had equal death rates at both points in time. Countries that lie above the grey line had higher death rates in 1990; for those that lie below the grey line, the opposite is true.

We see that almost all countries in the world lie above the grey line. This means that most countries have achieved a decline in death rates from smoking in recent decades.

Prevalence of smoking across the world

Share of smokers among the population.

Around one-in-four adults in the world smoke tobacco.

But where in the world is smoking most common?

In the map, we see the share of adults aged 15 years and older who smoke tobacco.

There are a number of countries where more than a third of the population smokes. The places where many people smoke are clustered in regions. South-East Asia, the Pacific islands, and parts of Europe.

In some countries, very few people smoke.

Several factors influence the prevalence of smoking. One is prosperity: if we look at the relationship between smoking prevalence and income, we find that richer countries tend to smoke more. But as you see in this correlation, there are very large differences at each level of income.

Smoking rates are high across many countries, but we know from the history of many countries that this can change quickly. Many of today’s high-income countries had much higher smoking rates in the past and have seen a large reduction.

The prevalence of smoking also differs significantly between men and women. In this article ,   we look at sex differences in smoking across the world.

Daily smokers

This visualization shows the share of adults, aged 15 years and older, who smoke every day.

We see that daily smoking is most common across Europe and Asia – more than 20% of adults in most countries in these regions smoke every day.

Related – number of daily smokers . This map shows the number of people who smoke every day across the world.

Smoking by gender

Nearly one-in-four adults in the world smokes tobacco . But there are large differences between men and women.

More than one-third of men in the world smoke. Less than one-in-ten women do.

In almost all countries, it is true that a large share of men smoke. In the visualization, we see the share of men who smoke (plotted on the vertical axis) compared with the same metric for women (plotted on the horizontal axis).

The grey line in the plot represents equality in the prevalence: countries where smoking is more common in men will lie above this line, and countries where more women smoke lie below.

We see that almost all countries lie above the grey line, meaning a higher share of men smoke. There are only a few exceptions.

In many countries — particularly across Asia and Africa — the differences are very large.

We also see this when we look at a global map of smoking among women : across much of Africa and Asia, rates are very low. For comparison, here is the world map of smoking rates in men .

The fact that men are more likely than women to smoke is reflected in health statistics, particularly lung cancer, for which smoking is a primary risk factor . We see that in nearly every country in the world, men are more likely to die from lung cancer.

Related – number of daily smokers by sex. This chart details the number of men and women who smoke daily.

How has the prevalence of smoking changed over time?

The rise and fall of smoking.

The smoking of cigarettes first saw a significant rise across today's rich countries in the early 20th century. Since then, trends in smoking have undergone a century-long cycle of peak and decline.

In the visualization, we see the average number of cigarettes sold per adult per day across many of today's rich countries, including the United States and European countries.

Here, we see that all countries followed a very similar trajectory: a steep rise in cigarette consumption during the early-to-mid 1900s, peaking from the mid-to-latter half of the century before entering into a steep decline in the decades which followed.

Notably, this rise-peak-fall pathway took around a century in all cases. This long trajectory has had major health impacts on the populations of rich countries today.

Smoking rates are now falling in almost all countries

The rise, peak, and decline of smoking in rich countries took around a century. The high peak had severe health impacts.

This timescale is important when we consider low-to-middle-income countries today: if they are to avoid the scale of the health consequences seen by rich countries, they must move through this pathway much quicker. The positive news is that most have – smoking is already falling in most countries today.

In this visualization, we see the share of adults who smoked in the year 2000 (on the y-axis) and in the most recent data (on the x-axis). The grey line here shows parity: countries that lie along this line would have the same smoking prevalence at both points in time. Countries that lie above this line had higher smoking prevalence back in 2000; for those below the opposite is true.

We see that most countries lie above the grey line: this means the share of adults who smoke has declined in most countries in the world over the past decade. This is a surprising fact to many, since it means smoking prevalence is not only falling in high-income countries but also in most low-to-middle incomes. 5

Low-to-middle income countries have effectively 'leapfrogged' the century-long rise-peak-decline pathway of rich countries. Almost everywhere, smoking is on the decline.

Smoking and cancer

The rise and fall of lung cancer.

This chart shows death rates from lung cancer in the US since 1950. It is possible to view the data for other countries by using the tools in the chart.

We see the same rise, peak, and decline pattern that we have seen in the cigarette consumption statistics.

These trends are largely driven by the trends in smoking . Smoking is the biggest risk factor for lung cancer and we see that the trends in lung cancer follow those in smoking with a lag.

Share of cancer deaths attributed to smoking

The world map shows the Global Burden of Disease estimates of the share of cancer deaths that can be attributed to smoking.

Globally, about a quarter of cancer deaths are attributed to smoking.

In most richer countries, the share is even higher.

In poor countries, where fewer people were smoking in the past, tobacco is responsible for a smaller fraction of cancer deaths.

What can be done to reduce smoking?

Pricing and taxes, affordability of cigarettes, taxes on cigarettes, bans on tobacco advertising, support to quit smoking, data sources, international mortality and smoking statistics (imass).

• Data:  Consumption of tobacco products, prevalence of smoking and mortality
• Geographical coverage:  30 countries
• Time span:  Often spanning back 100 years
• Available at:  Online here

Institute of Health Metrics and Evaluation (IHME), Global Burden of Disease (GBD)

• Data:  Death rates and absolute number of premature deaths from smoking and secondhand-smoke
• Geographical coverage: Global, across all regions and countries
• Time span: 1990 onwards

World Health Organization (WHO) Global Health Observatory (GHO)

• Data:  Smoking prevalence, prices, taxes and policy support

Interactive charts on smoking

Jha, P. (2009). Avoidable global cancer deaths and total deaths from smoking .  Nature Reviews Cancer ,  9 (9), 655.

WHO (2023) – Fact Sheet: Tobacco , updated in July 2023

The estimates of the Global Burden of Disease study can be found here . The latest study can be found at the website of The Lancet here: TheLancet.com/GBD

There are two publications that are closely related to the Global Burden of Disease study:

Reitsma et al. (2021) – Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019: A systematic analysis from the Global Burden of Disease Study 2019 . In The Lancet , 397(10292), 2337–2360.

The GBD estimates are also presented in yet another prominent publication. The Tobacco Atlas is published by the American Cancer Society and Vital Strategies and presents estimates for the global death toll from smoking taken from the Global Burden of Disease Study published by the Institute for Health Metrics and Evaluation (IHME).

Note that deaths from different risk factors are not summable .

Mathers, C. D., & Loncar, D. (2006). Projections of global mortality and burden of disease from 2002 to 2030.  PLoS medicine ,  3 (11), e442.

Jha, P., & Peto, R. (2014). Global effects of smoking, of quitting, and of taxing tobacco .  New England Journal of Medicine ,  370 (1), 60-68.

Bilano, V., Gilmour, S., Moffiet, T., d'Espaignet, E. T., Stevens, G. A., Commar, A., ... & Shibuya, K. (2015). Global trends and projections for tobacco use, 1990–2025: an analysis of smoking indicators from the WHO Comprehensive Information Systems for Tobacco Control .  The Lancet ,  385 (9972), 966-976.

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• Open access
• Published: 21 January 2021

The effects of tobacco control policies on global smoking prevalence

• Luisa S. Flor   ORCID: orcid.org/0000-0002-6888-512X 1 ,
• Marissa B. Reitsma 1 ,
• Vinay Gupta 1 ,
• Marie Ng   ORCID: orcid.org/0000-0001-8243-4096 2 &
• Emmanuela Gakidou   ORCID: orcid.org/0000-0002-8992-591X 1  

Nature Medicine volume  27 ,  pages 239–243 ( 2021 ) Cite this article

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• Risk factors

Substantial global effort has been devoted to curtailing the tobacco epidemic over the past two decades, especially after the adoption of the Framework Convention on Tobacco Control 1 by the World Health Organization in 2003. In 2015, in recognition of the burden resulting from tobacco use, strengthened tobacco control was included as a global development target in the 2030 Agenda for Sustainable Development 2 . Here we show that comprehensive tobacco control policies—including smoking bans, health warnings, advertising bans and tobacco taxes—are effective in reducing smoking prevalence; amplified positive effects are seen when these policies are implemented simultaneously within a given country. We find that if all 155 countries included in our counterfactual analysis had adopted smoking bans, health warnings and advertising bans at the strictest level and raised cigarette prices to at least 7.73 international dollars in 2009, there would have been about 100 million fewer smokers in the world in 2017. These findings highlight the urgent need for countries to move toward an accelerated implementation of a set of strong tobacco control practices, thus curbing the burden of smoking-attributable diseases and deaths.

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Decades after its ill effects on human health were first documented, tobacco smoking remains one of the major global drivers of premature death and disability. In 2017, smoking was responsible for 7.1 (95% uncertainty interval (UI), 6.8–7.4) million deaths worldwide and 7.3% (95% UI, 6.8%–7.8%) of total disability-adjusted life years 3 . In addition to the health impacts, economic harms resulting from lost productivity and increased healthcare expenditures are also well-documented negative effects of tobacco use 4 , 5 . These consequences highlight the importance of strengthening tobacco control, a critical and timely step as countries work toward the 2030 Sustainable Development Goals 2 .

In 2003, the World Health Organization (WHO) led the development of the Framework Convention on Tobacco Control (FCTC), the first global health treaty intended to bolster tobacco use curtailment efforts among signatory member states 1 . Later, in 2008, to assist the implementation of tobacco control policies by countries, the WHO introduced the MPOWER package, an acronym representing six evidence-based control measures (Table 1 ) (ref. 6 ). While accelerated adoption of some of these demand reduction policies was observed among FCTC parties in the past decade 7 , many challenges remain to further decrease population-level tobacco use. Given the differing stages of the tobacco epidemic and tobacco control across countries, consolidating the evidence base on the effectiveness of policies in reducing smoking is necessary as countries plan on how to do better. In this study, we evaluated the association between varying levels of tobacco control measures and age- and sex-specific smoking prevalence using data from 175 countries and highlighted missed opportunities to decrease smoking rates by predicting the global smoking prevalence under alternative unrealized policy scenarios.

Despite the enhanced global commitment to control tobacco use, the pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, sex and age 8 ; in 2017, there were still 1.1 billion smokers across the 195 countries and territories assessed by the Global Burden of Diseases, Injuries, and Risk Factors Study. Global smoking prevalence in 2017 among men and women aged 15 and older, 15–29 years, 30–49 years and 50 years and older are shown in Extended Data Figs. 1 , 2 , 3 and 4 , respectively. We found that, between 2009 and 2017, current smoking prevalence declined by 7.7% for men (36.3% (95% UI, 35.9–36.6%) to 33.5% (95% UI, 32.9–34.1%)) and by 15.2% for women globally (7.9% (95% UI, 7.8–8.1%) to 6.7% (95% UI, 6.5–6.9%)). The highest relative decreases were observed among men and women aged 15–29 years, at 10% and 20%, respectively. Conversely, prevalence decreased less intensively for those aged over 50, at 2% for men and 9.5% for women. While some countries have shown an important reduction in smoking prevalence between 2009 and 2017, such as Brazil, suggesting sustained progress in tobacco control, a handful of countries and territories have shown considerable increases in smoking rates among men (for example, Albania) and women (for example, Portugal) over this time period.

In an effort to counteract the harmful lifelong consequences of smoking, countries have, overall, implemented stronger demand reduction measures after the FCTC ratification. To assess national-level legislation quality, the WHO attributes a score to each of the MPOWER measures that ranges from 1 to 4 for the monitoring component (M) and 1–5 for the other components. A score of 1 represents no known data, while scores 2–5 characterize the overall strength of each measure, from the lowest level of achievement (weakest policy) to the highest level of achievement (strongest policy) 6 . Between 2008 and 2016, although very little progress was made in treatment provision (O) 7 , 9 , the share of the total population covered by best practice (score = 5) P, W and E measures increased (Fig. 1 ). Notably, however, a massive portion of the global population is still not covered by comprehensive laws. As an example, less than 15% of the global population is protected by strongly regulated tobacco advertising (E) and the number of people (2.1 billion) living in countries where none or very limited smoke-free policies (P) are in place (score = 2) is still nearly twice as high as the population (1.1 billion) living in locations with national bans on smoking in all public places (score = 5).

To assess national-level legislation quality, the WHO attributes a score to each MPOWER component that ranges from 1 to 5 for smoke-free (P), health warning (W) and advertising (E) policies. A score of 1 represents no known data or no recent data, while scores 2–5 characterize the overall strength of each policy, from 2 representing the lowest level of achievement (weakest policy), to 5 representing the highest level of achievement (strongest policy).

Source data

In terms of fiscal policies (R), the population-weighted average price, adjusted for inflation, of a pack of cigarettes across 175 countries with available data increased from I$3.10 (where I$ represents international dollars) in 2008 to I$5.38 in 2016. However, from an economic perspective, for prices to affect purchasing decisions, they need to be evaluated relative to income. The relative income price (RIP) of cigarettes is a measure of affordability that reflects, in this study, what proportion of the country-specific per capita gross domestic product (GDP) is needed to purchase half a pack of cigarettes a day for a year. Over time, cigarettes have become less affordable (RIP 2016 > RIP 2008) in about 75% of the analyzed countries, with relatively more affordable cigarettes concentrated across high-income countries.

Our adjusted analysis indicates that greater levels of achievement on key measures across the P, W and E policy categories and higher RIP values were significantly associated with reduced smoking prevalence from 2009 to 2017 (Table 2 ). Among men aged 15 and older, each 1-unit increment in achievement scores for smoking bans (P) was independently associated with a 1.1% (95% UI, −1.7 to −0.5, P  < 0.0001) decrease in smoking prevalence. Similarly, an increase of 1 point in W and E scores was associated with a decrease in prevalence of 2.1% (95% UI, −2.7 to −1.6, P  < 0.0001) and 1.9% (95% UI, −2.6 to −1.1, P  < 0.0001), respectively. Furthermore, a 10 percentage point increase in RIP was associated with a 9% (95% UI, −12.6 to −5.0, P  < 0.0001) decrease in overall smoking prevalence. Results were similar for men from other age ranges.

Among women, the magnitude of effect of different policy indicators varied across age groups. For those aged over 15, each 1-point increment in W and E scores was independently associated with an average reduction in prevalence of 3.6% (95% UI, −4.5 to −2.9, P  < 0.0001) and 1.9% (95% UI, −2.9 to −1.8, P  = 0.002), respectively, and these findings were similar across age groups. Smoking ban (P) scores were not associated with reduced prevalence among women aged 15–29 years or over 50 years. However, a 1-unit increase in P scores was associated with a 1.3% (95% UI, −2.3 to −0.2, P  = 0.016) decline in prevalence among women aged 30–49 years. Lastly, while a 10 percentage point increase in RIP lowered women smoking prevalence by 6% overall (95% UI, −10.0 to −2.0, P = 0.014), this finding was not statistically significant when examining reductions in prevalence among those aged 50 and older (Table 2 ).

If tobacco control had remained at the level it was in 2008 for all 155 countries (with non-missing policy indicators for both 2008 and 2016; Methods ) included in the counterfactual analysis, we estimate that smoking prevalence would have been even higher than the observed 2017 rates, with 23 million more male smokers and 8 million more female smokers (age ≥ 15) worldwide (Table 3 ). Out of the counterfactual scenarios explored, the greatest progress in reducing smoking prevalence would have been observed if a combination of higher prices—resulting in reduced affordability levels—and strictest P, W and E laws had been implemented by all countries, leading to lower smoking rates among men and women from all age groups and approximately 100 million fewer smokers across all countries (Table 3 ). Under this policy scenario, the greatest relative decrease in prevalence would have been seen among those aged 15–29 for both sexes, resulting in 26.6 and 6.5 million fewer young male and female smokers worldwide in 2017, respectively.

Our findings reaffirm that a wide spectrum of tobacco demand reduction policies has been effective in reducing smoking prevalence globally; however, it also indicates that even though much progress has been achieved, there is considerable room for improvement and efforts need to be strengthened and accelerated to achieve additional gains in global health. A growing body of research points to the effectiveness of tobacco control measures 10 , 11 , 12 ; however, this study covers the largest number of countries and years so far and reveals that the observed impact has varied by type of control policy and across sexes and age groups. In high-income countries, stronger tobacco control efforts are also associated with higher cessation ratios (that is, the ratio of former smokers divided by the number of ever-smokers (current and former smokers)) and decreases in cigarette consumption 13 , 14 .

Specifically, our results suggest that men are, in general, more responsive to tobacco control interventions compared to women. Notably, with prevalence rates for women being considerably low in many locations, variations over time are more difficult to detect; thus, attributing causes to changes in outcome can be challenging. Yet, there is already evidence that certain elements of tobacco control policies that play a role in reducing overall smoking can have limited impact among girls and women, particularly those of low socioeconomic status 15 . Possible explanations include the different value judgments attached to smoking among women with respect to maintaining social relationships, improving body image and hastening weight control 16 .

Tax and price increases are recognized as the most impactful tobacco control policy among the suite of options under the MPOWER framework 10 , 14 , 17 , particularly among adolescents and young adults 18 . Previous work has also demonstrated that women are less sensitive than men to cigarette tax increases in the USA 19 . Irrespective of these demographic differences, effective tax policy is underutilized and only six countries—Argentina, Chile, Cuba, Egypt, Palau and San Marino—had adopted cigarette taxes that corresponded to the WHO-prescribed level of 70% of the price of a full pack by 2017 (ref. 20 ). Cigarettes also remain highly affordable in many countries, particularly among high-income nations, an indication that affordability-based prescriptions to countries, instead of isolated taxes and prices reforms, are possibly more useful as a tobacco control target. In addition, banning sales of single cigarettes, restricting legal cross-border shopping and fighting illicit trade are required so that countries can fully experience the positive effect of strengthened fiscal policies.

Smoke-free policies, which restrict the opportunities to smoke and decrease the social acceptability of smoking 17 , also affect population groups differently. In general, women are less likely to smoke in public places, whereas men might be more frequently influenced by smoking bans in bars, restaurants, clubs and workplaces across the globe due to higher workforce participation rates 16 . In addition to leading to reduced overall smoking rates, as indicated in this study, implementing complete smoking bans (that is, all public places completely smoke-free) at a faster pace can also play an important role in minimizing the burden of smoking-attributable diseases and deaths among nonsmokers. In 2017 alone, 2.18% (95% UI, 1.8–2.7%) of all deaths were attributable to secondhand smoke globally, with the majority of the burden concentrated among women and children 21 .

Warning individuals about the harms of tobacco use increases knowledge about the health risks of smoking and promotes changes in smoking-related behaviors, while full advertising and promotion bans—implemented by less than 20% of countries in 2017 (ref. 20 )—are associated with decreased tobacco consumption and smoking initiation rates, particularly among youth 17 , 22 , 23 . Large and rotating pictorial graphic warnings are the most effective in attracting smokers’ attention but are lacking in countries with high numbers of smokers, such as China and the USA 20 . Adding best practice health warnings to unbranded packages seems to be an effective way of informing about the negative effects of smoking while also eliminating the tobacco industry’s marketing efforts of using cigarette packages to make these products more appealing, especially for women and young people who are now the prime targets of tobacco companies 24 , 25 .

While it is clear that strong implementation and enforcement are crucial to accelerating progress in reducing smoking and its burden globally, our heterogeneous results by type of policy and demographics highlight the challenges of a one-size-fits-all approach in terms of tobacco control. The differences identified illustrate the need to consider the stages 26 of the smoking epidemics among men and women and the state of tobacco control in each country to identify the most pressing needs and evaluate the way ahead. Smoking patterns are also influenced by economic, cultural and political determinants; thus, future efforts in assessing the effectiveness of tobacco control policies under these different circumstances are of value. As tobacco control measures have been more widely implemented, tobacco industry forces have expanded and threaten to delay or reverse global progress 27 . Therefore, closing loopholes through accelerated universal adoption of the comprehensive set of interventions included in MPOWER, guaranteeing that no one is left unprotected, is an urgent requirement as efforts toward achieving the Sustainable Development Goals by 2030 are intensified.

This was an ecological time series analysis that aimed to estimate the effect of four key demand reduction measures on smoking rates across 175 countries. Country-year-specific achievement scores for P, W and E measures and an affordability metric measured by RIP—to capture the impact of fiscal policy (R)—were included as predictors in the model. Although the WHO also calls for monitoring (M) and tobacco cessation (O) interventions, these were not evaluated. Monitoring tobacco use is not considered a demand reduction measure, while very little progress has been made in treatment provision over the last decade 7 , 9 . Further information on research design is available in the Life Sciences Reporting Summary linked to this paper.

Smoking outcome data

The dependent variable is represented by country-specific, age-standardized estimates of current tobacco smoking prevalence, defined as individuals who currently use any smoked tobacco product on a daily or occasional basis. Complete time series estimates of smoking prevalence from 2009 to 2017 for men and women aged 15–29, 30–49, 50 years and older and 15 years and older, were taken from the Global Burden of Disease (GBD) 2017 study.

The GBD is a scientific effort to quantify the comparative magnitude of health loss due to diseases, injuries and risk factors by age, sex and geography for specific points in time. While full details on the estimation process for smoking prevalence have been published elsewhere, we briefly describe the main analytical steps in this article 3 . First, 2,870 nationally representative surveys meeting the inclusion criteria were systematically identified and extracted. Since case definitions vary between surveys, for example, some surveys only ask about daily smoking as opposed to current smoking that includes both daily and occasional smokers, the extracted data were adjusted to the reference case definition using a linear regression fit on surveys reporting multiple case definitions. Next, for surveys with only tabulated data available, nonstandard age groups and data reported as both sexes combined were split using observed age and sex patterns. These preprocessing steps ensured that all data used in the modeling were comparable. Finally, spatiotemporal Gaussian process regression, a three-step modeling process used extensively in the GBD to estimate risk factor exposure, was used to estimate a complete time series for every country, age and sex. In the first step, estimates of tobacco consumption from supply-side data are incorporated to guide general levels and trends in prevalence estimates. In the second step, patterns observed in locations, age groups and years with smoking prevalence data are synthesized to improve the first-step estimates. This step is particularly important for countries and time periods with limited or no available prevalence data. The third step incorporates and quantifies uncertainty from sampling error, non-sampling error and the preprocessing data adjustments. For this analysis, the final age-specific estimates were age-standardized using the standard population based on GBD population estimates. Age standardization, while less important for the narrower age groups, ensured that the estimated effects of policies were not due to differences in population structure, either within or between countries.

Using GBD-modeled data is a strength of the study since nearly 3,000 surveys inform estimates and countries are not required to have complete survey coverage between 2009 and 2017 to be included in the analysis. Yet, it is important to note that these estimates have limitations. For example, in countries where a prevalence survey was not conducted after the enactment of a policy, modeled estimates may not reflect changes in prevalence resulting from that policy. Nonetheless, the prevalence estimates from the GBD used in this study are similar to those presented in the latest WHO report 28 , indicating the validity and consistency of said estimates.

MPOWER data

Summary indicators of country-specific achievements for each MPOWER measure are released by the WHO every two years and date back to 2007. Data from different iterations of the WHO Report on the Global Tobacco Epidemic (2008 6 , 2009 29 , 2011 30 , 2013 31 , 2015 32 and 2017 20 ) were downloaded from the WHO Tobacco Free Initiative website ( https://www.who.int/tobacco/about/en/ ). To assess the quality of national-level legislation, the WHO attributes a score to each MPOWER component that ranges from 1 to 4 for the monitoring (M) dimension and 1–5 for the other dimensions. A score of 1 represents no known data or no recent data, while scores 2–5 characterize the overall strength of each policy, from the lowest level of achievement (weakest policy) to the highest (strongest policy).

Specifically, smoke-free legislation (P) is assessed to determine whether smoke-free laws provide for a complete indoor smoke-free environment at all times in each of the respective places: healthcare facilities; educational facilities other than universities; universities; government facilities; indoor offices and workplaces not considered in any other category; restaurants or facilities that serve mostly food; cafes, pubs and bars or facilities that serve mostly beverages; and public transport. Achievement scores are then based on the number of places where indoor smoking is completely prohibited. Regarding health warning policies (W), the size of the warnings on both the front and back of the cigarette pack are averaged to calculate the percentage of the total pack surface area covered by the warning. This information is combined with seven best practice warning characteristics to construct policy scores for the W dimension. Finally, countries achievements in banning tobacco advertising, promotion and sponsorship (E) are assessed based on whether bans cover the following types of direct and indirect advertising: (1) direct: national television and radio; local magazines and newspapers; billboards and outdoor advertising; and point of sale (indoors); (2) indirect: free distribution of tobacco products in the mail or through other means; promotional discounts; nontobacco products identified with tobacco brand names; brand names of nontobacco products used or tobacco products; appearance of tobacco brands or products in television and/or films; and sponsorship.

P, W and E achievement scores, ranging from 2 to 5, were included as predictors into the model. The goal was to not only capture the effect of adopting policies at its highest levels but also assess the reduction in prevalence that could be achieved if countries moved into the expected direction in terms of implementing stronger measures over time. Additionally, having P, W and E scores separately, and not combined into a composite score, enabled us to capture the independent effect of different types of policies.

Although compliance is a critical factor in understanding policy effectiveness, the achievement scores incorporated in our main analysis reflect the adoption of legislation rather than degree of enforcement, representing a limitation of these indicators.

Prices in I$ for a 20-cigarette pack of the most sold brand in each of the 175 countries were also sourced from the WHO Tobacco Free Initiative website for all available years (2008, 2010, 2012, 2014 and 2016). I$ standardize prices across countries and also adjust for inflation across time. This information was used to construct an affordability metric that captures the impact of cigarette prices on smoking prevalence, considering the income level of each country.

More specifically, the RIP, calculated as the percentage of per capita GDP required to purchase one half pack of cigarettes a day over the course of a year, was computed for each available country and year. Per capita GDP estimates were drawn from the Institute for Health Metrics and Evaluation; the estimation process is detailed elsewhere 33 .

Given that the price data used in the analysis refer to the most sold brand of cigarettes only, it does not reflect the full range of prices of different types of tobacco products available in each location. This might particularly affect our power in detecting a strong effect in countries where other forms of tobacco are more popular.

Statistical analysis

Sex- and age-specific logit-transformed prevalence estimates from 2009 to 2017 were matched to one-year lagged achievement scores and RIP values using country and year identifiers 34 . The final sample consisted of 175 countries and was constrained to locations and years with non-missing indicators. A multiple linear mixed effects model fitted by restricted maximum likelihood was used to assess the independent effect of P, W and E scores and RIP values on the rates of current smoking. Specifically, a country random intercept and a country random slope on RIP were included to account for geographical heterogeneity and within-country correlation. The regression model takes the following general form:

where y c,t is the prevalence of current smoking in each country ( c ) and year ( t ), β 0 is the intercept for the model and β p , β w , β e and β r are the fixed effects for each of the policy predictors. \(\mathrm{P}_{c,\,t - 1},\,\mathrm{W}_{c,\,t - 1},\,\mathrm{E}_{c,\,t - 1}\) are the P, W and E scores and R c , t −1 is the RIP value for country c in year t  − 1. Finally, α c is the random intercept for country ( c ), while δ c represent the random slope for the country ( c ) to which the RIP value (R t − 1 ) belongs. Variance inflation factor values were calculated for all the predictor parameters to check for multicollinearity; the values found were low (<2) 35 . Bivariate models were also run and are shown in Extended Data Fig. 5 . The one-year lag introduced into the model may have led to an underestimation of effect sizes, particularly as many MPOWER policies require a greater period of time to be implemented effectively. However, due to the limited time range of our data (spanning eight years in total), introducing a longer lag period would have resulted in the loss of additional data points, thus further limiting our statistical power in detecting relevant associations between policies and smoking prevalence.

In addition to a joint model for smokers from both sexes, separate regressions were fitted for men and women and the four age groups (15–29, 30–49, ≥50 and ≥15 years old). To assess the validity of the mixed effects analyses, likelihood ratio tests comparing the models with random effects to the null models with only fixed effects were performed. Linear mixed models were fitted by maximum likelihood and t -tests used Satterthwaite approximations to degrees of freedom. P values were considered statistically significant if <0.05. All analyses were executed with RStudio v.1.1.383 using the lmer function in the R package lme4 v.1.1-21 (ref. 36 ).

A series of additional models to examine the impact of tobacco control policies were developed as part of this study. In each model, cigarette affordability (RIP) and a different set of policy metrics was used to capture the implementation, quality and compliance of tobacco control legislation. In models 1 and 2, we replaced the achievements scores by the proportion of P, W and E measures adopted by each country out of all possible measures reported by the WHO. In model 3, we used P and E (direct and indirect measures separately) compliance scores provided by the WHO to represent actual legislation implementation. Finally, an interaction term for compliance and achievement to capture the combined effect of legislation quality and performance was added to model 4. Results for men and women by age group for each of the additional models are presented in the Supplemental Information (Supplementary Tables 1–4 ).

The main model described in this study was chosen because it includes a larger number of country-year observations ( n  = 823) when compared to models including compliance scores and because it is more directly interpretable.

Counterfactual analysis

To further explore and quantify the impact of tobacco control policies on current smoking prevalence, we simulated what smoking prevalence across all countries would have been achieved in 2017 under 4 alternative policy scenarios: (1) if achievement scores and RIP remained at the level they were at in 2008; (2) if all countries had implemented each of P, W and E component at the highest level (score = 5); (3) if the price of a cigarette pack was I$7.73 or higher, a price that represents the 90th percentile of observed prices across all countries and years; and (4) if countries had implemented the P, W and E components at the highest level and higher cigarette prices. To keep our results consistent across scenarios, we restricted our analysis to 155 countries with non-missing policy-related indicators for both 2008 and 2016.

Random effects were used in model fitting but not in this prediction. Simulated prevalence rates were calculated by multiplying the estimated marginal effect of each policy by the alternative values proposed in each of the counterfactual scenarios for each country-year. The global population-weighted average was computed for status quo and counterfactual scenarios using population data sourced from the Institute for Health Metrics and Evaluation. Using the predicted prevalence rates and population data, the additional reduction in the number of current smokers in 2017 was also computed. Since models were ran using age-standardized prevalence, the number of smokers was proportionally redistributed across age groups using the sex-specific numbers from the age group 15 and older as an envelope.

The UIs for predicted estimates were based on a computation of the results of each of the 1,000 draws (unbiased random samples) taken from the uncertainty distribution of each of the estimated coefficients; the lower bound of the 95% UI for the final quantity of interest is the 2.5 percentile of the distribution and the upper bound is the 97.5 percentile of the distribution.

Reporting Summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

The dataset generated and analyzed during the current study is publicly available at http://ghdx.healthdata.org/record/ihme-data/global-tobacco-control-and-smoking-prevalence-scenarios-2017 ( https://doi.org/10.6069/QAZ7-6505 ). The dataset contains all data necessary to interpret, replicate and build on the methods or findings reported in the article. Tobacco control policy data that support the findings of this study are released every two years as part of the WHO’s Global Report on Tobacco Control; these data are also directly accessible at https://www.who.int/tobacco/global_report/en/ . Source data are provided with this paper.

Code availability

All code used for these analyses is available at http://ghdx.healthdata.org/record/ihme-data/global-tobacco-control-and-smoking-prevalence-scenarios-2017 and https://github.com/ihmeuw/team/tree/effects_tobacco_policies .

World Health Organization. WHO Framework Convention on Tobacco Control https://www.who.int/fctc/text_download/en/ (2003).

United Nations. Transforming Our World: the 2030 Agenda for Sustainable Development https://sustainabledevelopment.un.org/post2015/transformingourworld/publication (2015).

Stanaway, J. D. et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 392 , 1923–1994 (2018).

Article   Google Scholar  

Jha, P. & Peto, R. Global effects of smoking, of quitting, and of taxing tobacco. N. Engl. J. Med. 370 , 60–68 (2014).

Article   CAS   Google Scholar  

Ekpu, V. U. & Brown, A. K. The economic impact of smoking and of reducing smoking prevalence: review of evidence. Tob. Use Insights 8 , 1–35 (2015).

World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008: the MPOWER Package https://www.who.int/tobacco/mpower/2008/en/ (2008).

Chung-Hall, J., Craig, L., Gravely, S., Sansone, N. & Fong, G. T. Impact of the WHO FCTC over the first decade: a global evidence review prepared for the Impact Assessment Expert Group. Tob. Control 28 , s119–s128 (2019).

Reitsma, M. B. et al. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990–2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet 389 , 1885–1906 (2017).

Nilan, K., Raw, M., McKeever, T. M., Murray, R. L. & McNeill, A. Progress in implementation of WHO FCTC Article 14 and its guidelines: a survey of tobacco dependence treatment provision in 142 countries. Addiction 112 , 2023–2031 (2017).

Dubray, J., Schwartz, R., Chaiton, M., O’Connor, S. & Cohen, J. E. The effect of MPOWER on smoking prevalence. Tob. Control 24 , 540–542 (2015).

Anderson, C. L., Becher, H. & Winkler, V. Tobacco control progress in low and middle income countries in comparison to high income countries. Int. J. Environ. Res. Public Health 13 , 1039 (2016).

Gravely, S. et al. Implementation of key demand-reduction measures of the WHO Framework Convention on Tobacco Control and change in smoking prevalence in 126 countries: an association study. Lancet Public Health 2 , e166–e174 (2017).

Ngo, A., Cheng, K.-W., Chaloupka, F. J. & Shang, C. The effect of MPOWER scores on cigarette smoking prevalence and consumption. Prev. Med. 105S , S10–S14 (2017).

Feliu, A. et al. Impact of tobacco control policies on smoking prevalence and quit ratios in 27 European Union countries from 2006 to 2014. Tob. Control 28 , 101–109 (2019).

Google Scholar  

Greaves, L. Gender, equity and tobacco control. Health Sociol. Rev. 16 , 115–129 (2007).

Amos, A., Greaves, L., Nichter, M. & Bloch, M. Women and tobacco: a call for including gender in tobacco control research, policy and practice. Tob. Control 21 , 236–243 (2012).

Hoffman, S. J. & Tan, C. Overview of systematic reviews on the health-related effects of government tobacco control policies. BMC Public Health 15 , 744 (2015).

Chaloupka, F. J., Straif, K. & Leon, M. E. Effectiveness of tax and price policies in tobacco control. Tob. Control 20 , 235–238 (2011).

Rice, N., Godfrey, C., Slack, R., Sowden, A. & Worthy, G. A Systematic Review of the Effects of Price on the Smoking Behaviour of Young People (Centre for Reviews and Dissemination, 2009); https://www.crd.york.ac.uk/crdweb/ShowRecord.asp?LinkFrom=OAI&ID=12013060057&LinkFrom=OAI&ID=12013060057

World Health Organizaion. WHO Report on the Global Tobacco Epidemic 2017: Monitoring Tobacco Use and Prevention Policies https://www.who.int/tobacco/global_report/2017/en/ (2017).

Institute for Health Metrics and Evaluation. GBD Compare https://vizhub.healthdata.org/gbd-compare/ (2017).

Saffer, H. & Chaloupka, F. The effect of tobacco advertising bans on tobacco consumption. J. Health Econ. 19 , 1117–1137 (2000).

Noar, S. M. et al. The impact of strengthening cigarette pack warnings: systematic review of longitudinal observational studies. Soc. Sci. Med. 164 , 118–129 (2016).

Moodie, C., Brose, L. S., Lee, H. S., Power, E. & Bauld, L. How did smokers respond to standardised cigarette packaging with new, larger health warnings in the United Kingdom during the transition period? A cross-sectional online survey. Addict. Res. Theory 28 , 53–61 (2020).

Wakefield, M. et al. Australian adult smokers’ responses to plain packaging with larger graphic health warnings 1 year after implementation: results from a national cross-sectional tracking survey. Tob. Control 24 , ii17–ii25 (2015).

Thun, M., Peto, R., Boreham, J. & Lopez, A. D. Stages of the cigarette epidemic on entering its second century. Tob. Control 21 , 96–101 (2012).

Bialous, S. A. Impact of implementation of the WHO FCTC on the tobacco industry’s behaviour. Tob. Control 28 , s94–s96 (2019).

World Health Organization. Global Report on Trends in Prevalence of Tobacco Smoking 2000–2025 http://www.who.int/tobacco/publications/surveillance/trends-tobacco-smoking-second-edition/en/ (2018).

World Health Organization. WHO Report on the Global Tobacco Epidemic 2009: Implementing Smoke-Free Environments https://www.who.int/tobacco/mpower/2009/en/ (2009).

World Health Organization. WHO Report on the Global Tobacco Epidemic 2011: Warning About the Dangers of Tobacco https://www.who.int/tobacco/global_report/2011/en/ (2011).

World Health Organization. WHO Report on the Global Tobacco Epidemic 2013: Enforcing Bans on Tobacco Advertising, Promotion and Sponsorship https://www.who.int/tobacco/global_report/2013/en/ (2013).

World Health Organization. WHO Report on the Global Tobacco Epidemic 2015: Raising Taxes on Tobacco https://www.who.int/tobacco/global_report/2015/en/ (2015).

James, S. L., Gubbins, P., Murray, C. J. & Gakidou, E. Developing a comprehensive time series of GDP per capita for 210 countries from 1950 to 2015. Popul. Health Metr. 10 , 12 (2012).

Institute for Health Metrics and Evaluation. Global Tobacco Control and Smoking Prevalence Scenarios 2017 (dataset) (Global Health Data Exchange, 2020).

Zuur, A. F., Ieno, E. N. & Elphick, C. S. A protocol for data exploration to avoid common statistical problems. Methods Ecol. Evol. 1 , 3–14 (2010).

Bates, D., Mächler, M., Bolker, B. & Walker, S. Fitting linear mixed-effects models using lme4. J. Stat. Softw. https://doi.org/10.18637/jss.v067.i01 (2015).

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Acknowledgements

The study was funded by Bloomberg Philanthropies (grant 47386, Initiative to Reduce Tobacco Use). We thank the support of the Tobacco Metrics Team Advisory Group, which provided valuable comments and suggestions over several iterations of this manuscript. We also thank the Tobacco Free Initiative team at the WHO and the Campaign for Tobacco-Free Kids for making the tobacco control legislation data available and providing clarifications when necessary. We thank A. Tapp, E. Mullany and J. Whisnant for assisting in the management and execution of this study. We thank the team who worked in a previous iteration of this project, especially A. Reynolds, C. Margono, E. Dansereau, K. Bolt, M. Subart and X. Dai. Lastly, we thank all GBD 2017 Tobacco collaborators for their valuable work in providing feedback to our smoking prevalence estimates throughout the GBD 2017 cycle.

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Luisa S. Flor, Marissa B. Reitsma, Vinay Gupta & Emmanuela Gakidou

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L.S.F., M.N. and E.G. conceptualized the study and designed the analytical framework. M.B.R. and V.G. provided input on data, results and interpretation. L.S.F. and E.G. wrote the first draft of the manuscript. All authors read and approved the final version of the manuscript.

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Correspondence to Emmanuela Gakidou .

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Extended data

Extended data fig. 1 prevalence of current smoking for men (a) and women (b) aged 15 years and older (age-standardized) in 2017..

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 15 years and older for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 2 Prevalence of current smoking for men (a) and women (b) aged 15 to 29 years old (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 15–29 years old for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 3 Prevalence of current smoking for men (a) and women (b) aged 30 to 49 years old (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 30–49 years old for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 4 Prevalence of current smoking for men (a) and women (b) aged 50 years and older (age-standardized) in 2017.

Age-standardized smoking prevalence (%) estimates from the 2017 Global Burden of Disease Study for men (a) and women (b) aged 50 years and older for 195 countries. Smoking is defined as current use of any type of smoked tobacco product. Details on the estimation process can be found in the Methods section and elsewhere 3 .

Extended Data Fig. 5 Percentage changes in current smoking prevalence based on fixed effect coefficients from bivariate mixed effect linear regression models, by policy component, sex and age group.

Bivariate models examined the unadjusted association between smoke-free (P), health warnings (W), and advertising (E) achievement scores, and cigarette’s affordability (RIP) and current smoking prevalence, from 2009 to 2017, across 175 countries (n = 823 country-years). Linear mixed models were fit by maximum likelihood and t-tests used Satterthwaite approximations to degrees of freedom. P values were considered statistically significant if lower than 0.05.

Supplementary information

Supplementary information.

Supplementary Tables 1–4: additional models results.

Source Data Fig. 1

Input data for Fig. 1 replication.

Source Data Extended Data Fig. 1

Input data for Extended Data 1 replication.

Source Data Extended Data Fig. 2

Input data for Extended Data 2 replication.

Source Data Extended Data Fig. 3

Input data for Extended Data 3 replication.

Source Data Extended Data Fig. 4

Input data for Extended Data 4 replication.

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Flor, L.S., Reitsma, M.B., Gupta, V. et al. The effects of tobacco control policies on global smoking prevalence. Nat Med 27 , 239–243 (2021). https://doi.org/10.1038/s41591-020-01210-8

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Safe and effective pharmacotherapies and behavioral treatments already exist to help people quit smoking. Nicotine replacement therapies are available in several forms, including patches and over-the-counter gum that can ease nicotine craving without cancer-causing smoke. Varenicline and bupropion are prescription medications that can reduce nicotine cravings and withdrawal, and behavioral treatments like contingency management have been found to be effective at helping people quit. Combining behavioral treatments and pharmacotherapies may be most effective. And several promising new treatment approaches are also being studied and developed with NIDA funding.

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Current NIDA-funded projects also include studies of noninvasive brain stimulation (transcranial magnetic stimulation, TMS) for tobacco cessation; a trial of the safety and efficacy of an infusion of the dissociative drug ketamine for tobacco use disorder; a multi-site randomized controlled trial of the psychedelic drug psilocybin for tobacco use disorder; and trials of compounds with novel mechanisms of action in the brain, including a compound that interacts with a type of glutamate receptor (mGlu2) to reduce nicotine’s reinforcing effects.

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The science of whether vaping nicotine in e-cigarettes is effective in helping people quit smoking cigarettes is still evolving. A recent Cochrane review of 78 studies (with over 22,000 participants) found these devices to be more effective than nicotine replacement therapies in promoting quitting. A previous meta-analysis of real-world observational studies concluded that the use of e-cigarettes was not associated with smoking cessation, but results may have been affected by participants’ intention to quit .  

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What are some of the health problems caused by cigarette smoking?

Smoking is the leading cause of premature, preventable death in this country. Cigarette smoking and exposure to tobacco smoke cause about 480,000 premature deaths each year in the United States ( 1 ). Of those premature deaths, about 36% are from cancer, 39% are from heart disease and stroke , and 24% are from lung disease ( 1 ). Mortality rates among smokers are about three times higher than among people who have never smoked ( 6 , 7 ).

Smoking harms nearly every bodily organ and organ system in the body and diminishes a person’s overall health. Smoking causes cancers of the lung, esophagus, larynx, mouth, throat, kidney, bladder, liver, pancreas, stomach, cervix, colon, and rectum, as well as acute myeloid leukemia ( 1 – 3 ).

Smoking also causes heart disease, stroke, aortic aneurysm (a balloon-like bulge in an artery in the chest), chronic obstructive pulmonary disease (COPD) ( chronic bronchitis and emphysema ), diabetes , osteoporosis , rheumatoid arthritis, age-related macular degeneration , and cataracts , and worsens asthma symptoms in adults. Smokers are at higher risk of developing pneumonia , tuberculosis , and other airway infections ( 1 – 3 ). In addition, smoking causes inflammation and impairs immune function ( 1 ).

Since the 1960s, a smoker’s risk of developing lung cancer or COPD has actually increased compared with nonsmokers, even though the number of cigarettes consumed per smoker has decreased ( 1 ). There have also been changes over time in the type of lung cancer smokers develop – a decline in squamous cell carcinomas but a dramatic increase in adenocarcinomas . Both of these shifts may be due to changes in cigarette design and composition, in how tobacco leaves are cured, and in how deeply smokers inhale cigarette smoke and the toxicants it contains ( 1 , 8 ).

Smoking makes it harder for a woman to get pregnant. A pregnant smoker is at higher risk of miscarriage, having an ectopic pregnancy , having her baby born too early and with an abnormally low birth weight, and having her baby born with a cleft lip and/or cleft palate ( 1 ). A woman who smokes during or after pregnancy increases her infant’s risk of death from Sudden Infant Death Syndrome (SIDS) ( 2 , 3 ). Men who smoke are at greater risk of erectile dysfunction ( 1 , 9 ).

The longer a smoker’s duration of smoking, the greater their likelihood of experiencing harm from smoking, including earlier death ( 7 ). But regardless of their age, smokers can substantially reduce their risk of disease, including cancer, by quitting.

What are the risks of tobacco smoke to nonsmokers?

Secondhand smoke (also called environmental tobacco smoke, involuntary smoking, and passive smoking) is the combination of “sidestream” smoke (the smoke given off by a burning tobacco product) and “mainstream” smoke (the smoke exhaled by a smoker) ( 4 , 5 , 10 , 11 ).

The U.S. Environmental Protection Agency, the U.S. National Toxicology Program, the U.S. Surgeon General, and the International Agency for Research on Cancer have classified secondhand smoke as a known human carcinogen (cancer-causing agent) ( 5 , 11 , 12 ). Inhaling secondhand smoke causes lung cancer in nonsmoking adults ( 1 , 2 , 4 ). Approximately 7,300 lung cancer deaths occur each year among adult nonsmokers in the United States as a result of exposure to secondhand smoke ( 1 ). The U.S. Surgeon General estimates that living with a smoker increases a nonsmoker’s chances of developing lung cancer by 20 to 30% ( 4 ).

Secondhand smoke causes disease and premature death in nonsmoking adults and children ( 2 , 4 ). Exposure to secondhand smoke irritates the airways and has immediate harmful effects on a person’s heart and blood vessels. It increases the risk of heart disease by an estimated 25 to 30% ( 4 ). In the United States, exposure to secondhand smoke is estimated to cause about 34,000 deaths from heart disease each year ( 1 ). Exposure to secondhand smoke also increases the risk of stroke by 20 to 30% ( 1 ). Pregnant women exposed to secondhand smoke are at increased risk of having a baby with a small reduction in birth weight ( 1 ).        

Children exposed to secondhand smoke are at an increased risk of SIDS, ear infections, colds, pneumonia, and bronchitis. Secondhand smoke exposure can also increase the frequency and severity of asthma symptoms among children who have asthma. Being exposed to secondhand smoke slows the growth of children’s lungs and can cause them to cough, wheeze, and feel breathless ( 2 , 4 ).

Is smoking addictive?

Smoking is highly addictive. Nicotine is the drug primarily responsible for a person’s addiction to tobacco products, including cigarettes. The addiction to cigarettes and other tobacco products that nicotine causes is similar to the addiction produced by using drugs such as heroin and cocaine ( 13 ). Nicotine is present naturally in the tobacco plant. But tobacco companies intentionally design cigarettes to have enough nicotine to create and sustain addiction. 

The amount of nicotine that gets into the body is determined by the way a person smokes a tobacco product and by the nicotine content and design of the product. Nicotine is absorbed into the bloodstream through the lining of the mouth and the lungs and travels to the brain in a matter of seconds. Taking more frequent and deeper puffs of tobacco smoke increases the amount of nicotine absorbed by the body.

Are other tobacco products, such as smokeless tobacco or pipe tobacco, harmful and addictive?

Yes. All forms of tobacco are harmful and addictive ( 4 , 11 ). There is no safe tobacco product.

In addition to cigarettes, other forms of tobacco include smokeless tobacco , cigars , pipes , hookahs (waterpipes), bidis , and kreteks . 

• Smokeless tobacco : Smokeless tobacco is a type of tobacco that is not burned. It includes chewing tobacco , oral tobacco, spit or spitting tobacco, dip, chew, snus, dissolvable tobacco, and snuff. Smokeless tobacco causes oral (mouth, tongue, cheek and gum), esophageal, and pancreatic cancers and may also cause gum and heart disease ( 11 , 14 ).
• Cigars : These include premium cigars, little filtered cigars (LFCs), and cigarillos. LFCs resemble cigarettes, but both LFCs and cigarillos may have added flavors to increase appeal to youth and young adults ( 15 , 16 ). Most cigars are composed primarily of a single type of tobacco (air-cured and fermented), and have a tobacco leaf wrapper. Studies have found that cigar smoke contains higher levels of toxic chemicals than cigarette smoke, although unlike cigarette smoke, cigar smoke is often not inhaled ( 11 ). Cigar smoking causes cancer of the oral cavity, larynx, esophagus, and lung. It may also cause cancer of the pancreas. Moreover, daily cigar smokers, particularly those who inhale, are at increased risk for developing heart disease and other types of lung disease.
• Pipes : In pipe smoking, the tobacco is placed in a bowl that is connected to a stem with a mouthpiece at the other end. The smoke is usually not inhaled. Pipe smoking causes lung cancer and increases the risk of cancers of the mouth, throat, larynx, and esophagus ( 11 , 17 , 18 ).
• Hookah or waterpipe (other names include argileh, ghelyoon, hubble bubble, shisha, boory, goza, and narghile): A hookah is a device used to smoke tobacco (often heavily flavored) by passing the smoke through a partially filled water bowl before being inhaled by the smoker. Although some people think hookah smoking is less harmful and addictive than cigarette smoking ( 19 ), research shows that hookah smoke is at least as toxic as cigarette smoke ( 20 – 22 ).
• Bidis : A bidi is a flavored cigarette made by rolling tobacco in a dried leaf from the tendu tree, which is native to India. Bidi use is associated with heart attacks and cancers of the mouth, throat, larynx, esophagus, and lung ( 11 , 23 ).
• Kreteks : A kretek is a cigarette made with a mixture of tobacco and cloves. Smoking kreteks is associated with lung cancer and other lung diseases ( 11 , 23 ).

Is it harmful to smoke just a few cigarettes a day?

There is no safe level of smoking. Smoking even just one cigarette per day over a lifetime can cause smoking-related cancers (lung, bladder, and pancreas) and premature death ( 24 , 25 ).

What are the immediate health benefits of quitting smoking?

The immediate health benefits of quitting smoking are substantial:

• Heart rate and blood pressure , which are abnormally high while smoking, begin to return to normal.
• Within a few hours, the level of carbon monoxide in the blood begins to decline. (Carbon monoxide reduces the blood’s ability to carry oxygen.)
• Within a few weeks, people who quit smoking have improved circulation, produce less phlegm , and don’t cough or wheeze as often.
• Within several months of quitting, people can expect substantial improvements in lung function ( 26 ).
• Within a few years of quitting, people will have lower risks of cancer, heart disease, and other chronic diseases than if they had continued to smoke.

What are the long-term health benefits of quitting smoking?

Quitting smoking reduces the risk of cancer and many other diseases, such as heart disease and COPD , caused by smoking.

Data from the U.S. National Health Interview Survey show that people who quit smoking, regardless of their age, are less likely to die from smoking-related illness than those who continue to smoke. Smokers who quit before age 40 reduce their chance of dying prematurely from smoking-related diseases by about 90%, and those who quit by age 45-54 reduce their chance of dying prematurely by about two-thirds ( 6 ).

Regardless of their age, people who quit smoking have substantial gains in life expectancy, compared with those who continue to smoke. Data from the U.S. National Health Interview Survey also show that those who quit between the ages of 25 and 34 years live about 10 years longer; those who quit between ages 35 and 44 live about 9 years longer; those who quit between ages 45 and 54 live about 6 years longer; and those who quit between ages 55 and 64 live about 4 years longer ( 6 ).

Also, a study that followed a large group of people age 70 and older ( 7 ) found that even smokers who quit smoking in their 60s had a lower risk of mortality during follow-up than smokers who continued smoking.

Does quitting smoking lower the risk of getting and dying from cancer?

Yes. Quitting smoking reduces the risk of developing and dying from cancer and other diseases caused by smoking. Although it is never too late to benefit from quitting, the benefit is greatest among those who quit at a younger age ( 3 ).

The risk of premature death and the chances of developing and dying from a smoking-related cancer depend on many factors, including the number of years a person has smoked, the number of cigarettes smoked per day, and the age at which the person began smoking.

Is it important for someone diagnosed with cancer to quit smoking?

Quitting smoking improves the prognosis of cancer patients. For patients with some cancers, quitting smoking at the time of diagnosis may reduce the risk of dying by 30% to 40% ( 1 ). For those having surgery, chemotherapy, or other treatments, quitting smoking helps improve the body’s ability to heal and respond to therapy ( 1 , 3 , 27 ). It also lowers the risk of pneumonia and respiratory failure ( 1 , 3 , 28 ). In addition, quitting smoking may lower the risk that the cancer will recur, that a second cancer will develop, or that the person will die from the cancer or other causes ( 27 , 29 – 32 ).

Where can I get help to quit smoking?

NCI and other agencies and organizations can help smokers quit:

• Visit Smokefree.gov for access to free information and resources, including Create My Quit Plan , smartphone apps , and text message programs
• Call the NCI Smoking Quitline at 1–877–44U–QUIT ( 1–877–448–7848 ) for individualized counseling, printed information, and referrals to other sources.
• See the NCI fact sheet Where To Get Help When You Decide To Quit Smoking .

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Decline in smoking stalled after pandemic, study reveals

Read: The Telegraph (£) ; More: Daily Mail (1), Daily Mail (2) , Independent , Shropshire Star; UCL News  

• Open access
• Published: 03 May 2024

Exploring the opinions and potential impact of unflavoured e-liquid on smoking cessation among people who smoke and smoking relapse among people who previously smoked and now use e-cigarettes: findings from a UK-based mixed methods study

• Jasmine N. Khouja 1 , 2 ,
• Maddy L. Dyer 1 , 2 ,
• Michelle A. Havill 3 ,
• Martin J. Dockrell 3 ,
• Marcus R. Munafò 1 , 2 , 4 &
• Angela S. Attwood 1 , 2  

Harm Reduction Journal volume  21 , Article number:  90 ( 2024 ) Cite this article

352 Accesses

28 Altmetric

Metrics details

Although electronic cigarettes (e-cigarettes) appear to be effective in helping people who smoke to stop smoking, concerns about use of e-cigarettes among young people have led to restrictions on non-tobacco flavoured e-liquids in some countries and some US states. These restrictions could reduce the appeal of these products to non-smoking youth but could have negative consequences for people who smoke or use e-cigarettes.

In this mixed methods study, we recruited UK adults who smoked or used to smoke and subsequently vaped to explore their opinions of unflavoured e-liquids and their beliefs about how they would be impacted by hypothetical e-liquid flavour restrictions. Participants trialled an unflavoured e-liquid instead of their usual nicotine product for four hours and completed a survey and an online interview.

Using Interpretive Phenomenological Analysis and graphically presented data, we found differences in participants’ opinions of unflavoured e-liquid. If only unflavoured, tobacco flavoured, and menthol flavoured e-liquids remained on the UK market, some people who smoke or vape may be unaffected, but some may relapse to smoking or continue smoking. Despite most wanting to prevent young people from initiating vaping, participants had varying opinions on whether flavour restrictions would be an effective method.

Conclusions

The findings highlight that people who smoke and vape could be impacted by flavour restrictions in a range of ways, some of which could have a potential adverse impact on harm reduction efforts in the UK (e.g., by making smoking more appealing than vaping).

Electronic cigarettes (also known as e-cigarettes or vapes) are battery-operated devices that heat a liquid (also known as e-liquid) to create an aerosol, which can be inhaled. Using e-cigarettes is sometimes referred to as ‘vaping’ [ 33 ]. With approximately 4.7 million people who vape in Great Britain, many people use e-cigarettes to cut down or stop smoking [ 4 ]. A living systematic review of e-cigarette use for smoking cessation suggests that e-cigarettes are an effective smoking cessation aid [ 31 ]. The efficacy of e-cigarettes as smoking cessation tools may be partly dependent on the array of flavours available to aid or maintain smoking reduction or cessation [ 23 ], but some countries and US states have policies restricting e-liquid flavour availability. At a federal level, the USA only permits tobacco and menthol flavours in certain products, but in some US states this flavour ban applies to all e-cigarette products, and Finland only permits tobacco flavours. In January 2024, the UK government announced they will be introducing new powers to restrict flavours in e-cigarettes. Given that e-cigarettes have the potential to reduce harm at a population-level, it is important to understand the impact that restrictions may have on people who smoke and people who have quit smoking and switched to vaping in the UK.

E-liquid restrictions have been implemented in some countries and US states due to the belief that flavoured e-liquids appeal to non-smoking youth [ 47 ]. It has been suggested that e-cigarettes may attract youth who have never smoked, and that using e-cigarettes could lead to smoking initiation, commonly known as the “gateway effect” [ 14 ]. Research has found a strong positive association between e-cigarette use and later smoking among individuals who have not smoked prior to using e-cigarettes [ 5 ]. However, evidence from time-series analyses in England have not supported this theory [ 6 ] and the association could be due to the two behaviours sharing a common liability, for example a propensity to risk-taking [ 28 ]. Nevertheless, these concerns have led to e-liquid flavour restrictions in some countries and US states, and similar restrictions have been announced in the UK. This is despite little being known about the potential negative unintended public health consequences of such restrictions for UK adults who smoke or previously smoked and now vape.

Restrictions on the sale of flavoured e-liquids could result in people who transitioned from smoking to vaping returning to smoking (i.e., relapsing). Just under one in five people who use e-cigarettes surveyed in Great Britain stated that they would smoke more or revert to smoking if flavours were no longer available [ 3 ]. People who smoke may also be less interested in using e-cigarettes to stop smoking without the availability of a range of flavours.

If the number of adults who return to smoking or decide not to stop smoking using an e-cigarette outweighs the number of young people who are protected from vaping (and potentially subsequent smoking), then restrictions of e-liquid flavours could result in a net increase in the number of people who smoke in the population [ 24 ]. Current evidence suggests that cigarettes pose a much greater health risk than e-cigarettes [ 34 ], so the number of young people protected may need to substantially outweigh the number of people who return to or continue smoking cigarettes, to result in a net decrease in population harm. Alternatively, if people who smoke or vape positively perceive e-liquids which would remain on the market in the event of a flavour restriction (e.g., unflavoured e-liquid), then the overall impact of e-liquid flavour restrictions on people who smoke or used to smoke and now vape could be negligible. If they believe that flavour restrictions would have little impact on their behaviour (i.e., they would be just as likely to attempt to stop smoking and would be no more likely to return to smoking) then flavour restrictions could result in fewer people smoking in the population. Although unflavoured e-liquids (i.e., e-liquids containing propylene glycol, vegetable glycerin and nicotine without flavourings) would be available if these hypothetical restrictions were implemented, only 1.4% of adults who vaped in the UK in 2023 reported using unflavoured products [ 4 ], so some people who vape or smoke in the UK could be undecided about unflavoured e-liquid.

Understanding the opinions of people who smoke or previously smoked and now vape about unflavoured e-liquids could inform policies. It is also important to understand how people who smoke or previously smoked and now vape believe their future e-cigarette use, smoking behaviours, and behavioural intentions may be impacted by e-liquid flavour restrictions (e.g., banning all e-liquid flavourings except menthol and tobacco). There have been few qualitative explorations of the impact of e-liquid flavour bans or restrictions. One study focused on young US adults who smoked and vaped, finding that banning or restricting flavours (aside from tobacco, menthol or unflavoured e-liquids) could discourage them [ 15 ]. Another study among young adults in China who vaped daily for at least three months found they had used a range of adaptative strategies in the 1–3 months since [ 52 ]. These strategies included sourcing illegal products and using custom-made cartridge covers which added flavours to add flavours to legal products. After a restriction on flavoured cartridge-based vaping products in the US, young adults reported stockpiling, buying illegal products online, switching to legal flavours, and reducing use, but stated they might stop vaping, switch to cigarettes, or stockpile if flavours were comprehensively restricted in all vaping products [ 41 ]. These results cannot be generalised to adults who smoke or vape in other countries with different regulations, available products, and societal contexts. Among i) adults who currently smoke and ii) adults who currently vape (who have stopped smoking within the last 12 months) in the UK, we aimed to explore: 1) their opinions of unflavoured e-liquid after a brief trial (4 h) of an unflavoured e-liquid, and 2) how participants believe a hypothetical e-liquid flavour restriction (i.e., banning non-tobacco and non-menthol flavoured e-liquids) may impact their future smoking behaviour, vaping, and future intentions to vape unflavoured e-liquids.

This exploratory observational study using mixed methods followed the methods outlined in our online pre-registered study protocol ( https://osf.io/snmp9 ), except where specified. Ethics approval was obtained from the University of Bristol School of Psychological Science Human Research Ethics Committee, a subcommittee of the Faculty of Life Sciences Ethics Committee (reference: 010421116008).

Participants

We recruited 24 healthy UK residents between April 2021 and July 2021—12 adults who smoked daily and 12 adults who vaped daily (who stopped smoking within the 12 months prior to the study session) as daily vaping is strongly associated with smoking cessation and daily smoking is associated with using a quit aid in a smoking cessation attempt [ 25 , 48 ]. We recruited four people who smoked 20 or more cigarettes per day (CPD) and two people who vaped daily but used to smoke 20 or more CPD (two fewer than stated in our preregistered protocol due to difficulties in recruitment). A previous qualitative study exploring perceptions of e-liquid flavours among young adults who both smoked and vaped in the US included 25 interviews [ 15 ], therefore, we anticipated that 24 interviews would be sufficient to achieve saturation of themes [ 50 ]. Participants were recruited through existing email lists, social media (Facebook and Twitter adverts), word of mouth, and via the University of Bristol Tobacco and Alcohol Research Group (TARG) newsletter and website.

Participants were 18 years of age or older, fluent in English, and they self-identified as either a person who smoked daily or a person who vaped daily. Daily smoking was defined as currently smoking five or more times per day for three months or more. Participants who smoked were not currently attempting to stop smoking (i.e., not currently using nicotine replacement products or in active smoking cessation treatment) and were not currently vaping. Daily vaping was defined as currently using a nicotine-containing e-cigarette five or more times per day for three months or more. Participants who vaped daily and previously smoked had recently stopped smoking. This was defined as having previously met the criterion of currently smoking in the 12 months before the study and having replaced smoking with use of an e-cigarette for at least one month before the study. From here on, we refer to these participants as “participants who vaped”. Participants who vaped were required to currently only be using non-tobacco and non-menthol flavoured e-liquids (e.g., fruit flavoured e-liquids). Full eligibility criteria are listed in Additional file 1 (Sect. 1.1). All eligibility criteria were assessed via self-report, and nicotine use and pregnancy criteria were verified using self-administered urine tests. Presence of cotinine in urine, a highly specific biomarker for nicotine [ 7 ], was used to confirm current nicotine use.

Measures and materials

E-cigarette and e-liquid.

Participants received an Arc 5 starter kit purchased from Totally Wicked ( https://www.totallywicked-eliquid.co.uk/arc-5 ). Each kit contained one e-cigarette with a 2200 mAh internal battery, a CS Air Slim tank, and an atomizer head, a USB charging cable, and a user manual. A tank-style device was selected as it was the most popular device type among adults who regularly vape in Great Britain at the time of the study [ 3 ]. Each participant received one 10 ml bottle of unflavoured Red Label e-liquid (50:50 PG/VG) ( https://www.totallywicked-eliquid.co.uk/unflavoured-red-label . The e-liquid contained one of two nicotine concentrations (10 mg/ml or 18 mg/ml that best reflected a participant’s typical nicotine use (based on CPD or usual e-liquid nicotine concentration; Additional file 1 , Sect. 1.2).

Age, gender, ethnicity, and where applicable, frequency and duration of current and/or past smoking, frequency and duration of current and/or past e-cigarette use, and time since smoking cessation were recorded in a Qualtrics survey [ 40 ] (Additional file 2 : Tables S1 and S2). Descriptive quantitative data on participant characteristics and perceptions of unflavoured e-liquids prior to exposure were collected. Items measured participants’ willingness and intentions to use unflavoured e-liquids if flavoured e-liquids (i.e., non-tobacco, non-menthol flavoured) were restricted. Participants who smoked were asked if they would be willing to attempt to stop smoking using an e-cigarette, and with unflavoured e-liquid. Motivation to quit smoking was measured using the readiness to quit ladder [ 1 ]. The readiness to quit ladder ranges from 1 (“I have decided not to quit smoking for my lifetime. I have no interest in quitting”) to 10 (“I have quit smoking”). Participants who vaped were asked to report how many times per day they used their e-cigarette and were advised to assume that one ‘time’ lasts for around 10 min or consists of around 15 puffs [ 21 ]. Participants who vaped were asked: (a) if they believed they would have quit smoking using an e-cigarette if they had used an unflavoured e-liquid, (b) if they thought they would switch to using an unflavoured e-liquid if flavours were restricted, and (c) if they thought they would relapse to smoking instead of switching from a flavoured to an unflavoured e-liquid if e-liquid flavours were restricted. They were then asked what they would do if flavoured e-liquids were removed from the market (e.g., no sweet or fruit flavours), and only tobacco, menthol/mint and unflavoured e-liquids were available. They could select multiple answers from the options provided, and/or insert another answer. These questions and response options are described in full in Additional file 2 : Tables S1 and S2.

The semi-structured interview included open-ended questions that were intended to encourage the participants to discuss: (1) their experience and opinions of using unflavoured e-liquid, and (2) how they perceived a restriction on e-liquid flavours may impact their future smoking behaviour, vaping, and future intentions to vape unflavoured e-liquids. Specifically, participants were asked to consider a proposed scenario in which “flavoured e-liquids were removed from the market, and only unflavoured, tobacco or menthol/mint flavours were available”. We additionally asked about their previous experiences with smoking and vaping, and their general thoughts on the hypothetical proposed restrictions. The full interview schedule (including topic guide) is included in Additional file 2 : Tables S3 [for people who smoked] and S4 [for people who vaped]). The topic guide was developed based on existing literature [ 12 , 54 ] and known evidence gaps (detailed in the introduction).

Potential participants self-reported their eligibility to participate during a telephone screening and completed an online written consent form via Qualtrics. Participants provided a postal address. This first session lasted ~ 20 min. Following the telephone screening, the researcher posted an e-cigarette starter kit, objective screening tests (for cotinine and pregnancy, if female), instructions, a cleaning wipe (for the device), and a cover letter to the participant via Royal Mail. The e-cigarette voltage was set to 12W, but participants were instructed to modify this if desired.

Approximately one week later, on the morning of their test session day, the participant completed the objective screening measures (a cotinine test and if female, a pregnancy test). These screening sessions were via video call [ 55 ] and were scheduled between 8 am and 1 pm on the same day of the urine test(s). In the final screening session, the participant showed their cotinine (and if applicable, pregnancy) test results to the researcher on camera. Eligible participants were sent a link to an online Qualtrics survey via email to progress to Session 1 of the study. The survey assessed participant characteristics and participants’ perceptions of unflavoured e-liquids and e-liquid flavour restrictions. Following survey completion, the researcher instructed the participant to set up their e-cigarette, fill it with the e-liquid provided, and use this device instead of smoking or using their usual vaping products until Session 2 (~ 4 h later). Final screening and Session 1 were completed during one video call lasting ~ 20 min.

In Session 2, participants reported their puff count (recorded by the e-cigarette), provided verbal consent to begin the audio recording of the interview, and completed a semi-structured interview via a video call [ 55 ]. After the interview, participants were emailed a debrief sheet and a voucher for participation (worth £20). Interviews usually lasted 15–25 min and were transcribed verbatim.

Analyses and interpretation

We report all quantitative data for participants who smoked and participants who vaped separately due to differences in the survey questions. In contrast to our pre-registered protocol, we have not graphically presented the interview responses regarding predicted behaviour in response to flavour restrictions, intentions, and willingness to vape or use unflavoured e-liquids, as the responses were ambiguous in many cases, making quantification imprecise.

We used Interpretative Phenomenological Analysis (IPA) to analyse the qualitative data. IPA is a methodology in which the analyst takes an active role in interpreting how participants make sense of their social and personal world [ 45 ]. The most common IPA approach is to use transcripts from semi-structured interviews to identify common themes to explore the personal perceptions or accounts of an event [ 46 ]. In this analysis, two researchers analysed 50% of the data each by transcribing the recordings, reading the transcriptions, and making notes (i.e., coding the transcript). This process was repeated by a third researcher who resolved any disagreements about codes between the other researchers. The third researcher then compiled emerging themes by condensing the related notes into concise phrases which referred to a higher-level concept. The themes were then clustered into superordinate and subthemes by identifying conceptual similarities between them. Finally, we reviewed the themes in relation to the transcript notes to check that they suitably reflected the notes and were named appropriately.

Participant characteristics and baseline data

Participants who smoked and participants who vaped were similar in age (ranging from 19 to 62 years), gender, ethnicity, number of cigarettes smoked (currently or in the past) and smoking history (Table  1 ). Participants who vaped reported using a range of e-liquid nicotine strengths (some reported using more than one), but all participants used less than 19 mg/ml (in line with UK regulations). All participants used fruit flavoured e-liquids, but some participants also reported using other flavours (either in the survey or during the interview) such as “pastry flavours”. Responses to this questionnaire item, such as "various berry flavours”, limited our ability to determine how many flavours or which specific flavours were used by each participant (Additional file 2 : Table S5). Participants reported the average puff count (84 for participants who smoked and 83 for participants who vaped) and duration (8 min, 56 s for participants who smoked and 7 min, 23 s for participants who vaped) displayed on the e-cigarette device. Frequency of e-cigarette use can be difficult for people who vape to estimate [ 21 ] and at least one participant reported the number of puffs they took per day instead of the number of times they vaped per day.

Baseline quantitative data regarding predicted behaviour in response to flavour restrictions, intentions, and willingness to vape or use unflavoured e-liquids are presented in Figs. 1 , 2 , 3 .

Actions that people who previously smoked and subsequently vaped would take if there was an e-liquid flavour restriction (N = 12). Participants responded to multiple choice questions relating to a hypothetical flavour restriction in which only unflavoured, tobacco flavoured, and menthol flavoured e-liquids remained on the market (recorded at baseline)

Perceived success of participants who used a vape to stop smoking if they had used unflavoured e-liquid to stop smoking instead (N = 12). Participants responded to the question: "If you had used an unflavoured e-liquid when you quit smoking, do you think you would have successfully quit?" (recorded at baseline)

Participants’ willingness and intentions to vape or vape unflavoured e-liquid. Response options were “Yes” or ‘No”, with no “Maybe” option in the survey for participants who used to smoke and subsequently vaped. Responses were recorded at baseline

We identified six superordinate themes through IPA (Table  2 ). The ‘intentions and motivations to stop smoking and/or use e-cigarettes’ theme provides insights into the participants’ past and/or future likelihood of smoking and vaping irrespective of a flavour restriction. As this provides context but does not answer our research question, it can be found in Additional file 1 , Sect. 2.1. Other superordinate themes are discussed below except for subthemes which were infrequently raised or ambiguously linked to the superordinate theme ‘other drivers of vaping behaviour are more important than flavours’ (Additional file 1 , Sect. 2.2). For clarity, we indicate which participants vape and which smoke with a ‘V’ or ‘S’, respectively, at the end of their participant number.

Sensations and experience of using unflavoured e-liquid

In this theme, participants described the ‘sensations and experience of using unflavoured e-liquid’. Participants often described their experience of using the unflavoured e-liquid in terms of the harshness and throat hit, with people who vaped usually describing a harsher experience than their usual product and people who smoked describing a lesser throat hit compared to smoking. P015V said “I thought it felt quite harsh” and P020V stated, “it was just like nothing, except like just the harsh feeling of the smoke itself.” In contrast, P025S said, “There was no coughing or that harshness which is something you have when you have a cigarette” and P022S said “it didn’t really give that hit on the erm… throat that the cigarettes normally give you.”

The majority of participants who smoked thought the unflavoured e-liquid satisfied their cravings for cigarettes or nicotine but for others, it did not satisfy other elements of cigarette enjoyment. P001S said, “it gave me nicotine, and like I didn’t crave a smoke at all” and P012S said, “it definitely eliminated my cravings for cigarettes because I was constantly reaching for [the e-cigarette].” P021S said “I’d definitely say it hit the […] nicotine craving, but probably not the sort of unconscious pleasure I get from sort of having a cigarette compared to a vape.” P002S thought that the remaining craving was for the “ritual of smoking as opposed to like just the nicotine side of it.” Some participants who vaped also stated that the unflavoured e-liquid satisfied their cravings for nicotine, but they did not enjoy the experience. When P014V was asked “did you enjoy using it?”, they responded, “I kind of did in a way, because […] it’s satisfying a craving, the craving for nicotine, […] but the thing that I disliked really was the fact that it’s unflavoured”. P009V said the unflavoured e-liquid “quelled the, the want for […] nicotine generally, but I, I didn’t enjoy the experience, which I would normally with the flavoured stuff.”

Some participants commented on the similarities between smoking and using the unflavoured e-liquid. Most participants who smoked made general comparisons about vaping which were not specific to the unflavoured e-liquids, but P022S stated, “in terms of taste I cannot say that I’ve seen any noticeable difference [between using unflavoured e-liquid and smoking], which is good because it can serve as a replacement.” P002S said “I’ve tried the tobacco [e-liquids] and they’re not, they’re not quite like tobacco […] there’s more of a resemblance in the unflavoured one.” P020V was less positive about the similarity and said, “obviously it is unflavoured, and it, it didn’t have a flavour, but at the same time, it did, in the sense of, it’s just, it was just harsh, and dry […] like smoking”. P023S said, “I know it’s designed to simulate tobacco, which it does sort of an alright job of, but it’s basically the same but slightly more horrible.”

Participants generally had no expectations or negative expectations prior to using the unflavoured e-liquid. Where participants had no expectations, it was usually because they had not heard of unflavoured e-liquids. P015V stated, “I didn’t actually know they existed, I thought it was just tobacco, menthol and the other flavours”, and “I didn’t really have an opinion I just thought, ‘this is going to be horrible’”. Among those who had negative opinions prior to using the unflavoured e-liquid, some were pleasantly surprised; P014V said, “I felt like I was gonna be ripping me hair out for four hours, [because] I haven’t got my normal berry vape with me, but it wasn’t actually that bad really”. Others had their negative expectations confirmed, like P017V: “I expected it to be pretty bad, and it was pretty bad” and “it can’t even stand in the shadow of what I normally vape.” Participants who smoked tended not to have strong expectations about the unflavoured e-liquid prior to trying it, but some were positive after. For example, P003S admitted “I didn’t think I was going to enjoy it, and I didn’t see the point in having an unflavoured one, but actually […] I didn’t mind it and it was, it was quite nice.” P021S said, “unflavoured liquid would be the way I would go if I decided to take up vaping in the future”. Some participants who smoked were ambivalent after trying unflavoured e-liquids. P011S shared, “I thought it was going to taste worse than it did. […] I didn’t have any like ‘wow this is amazing’ either.” Some participants who smoked had negative opinions of the unflavoured e-liquid, like P023S who described it as “a flavour that you’d rather not have”.

There were mixed opinions among participants who vaped. P004V and P006V found it “worse” than they expected and P020V’s ambivalent opinion changed to it being “vile” after trying the e-liquid. P020V said, “you might as well just not have anything or […] not quit smoking.” P017V said “unflavoured’s pretty grim” and “it’s like having unflavoured toast, you’re not just gonna have like a bit of toast in the morning with nothing on it, are you? Like you probably could, you wouldn’t enjoy it, but, if you can, chuck a bit of flavour on there.” P019V said “It’s like drinking water instead of squash” and “I’m not sure I would choose the unflavoured again” because they preferred “fruity.” Some participants who vaped were more positive, for example P013V said, “I wouldn’t of chose it, but […] it’s alright” and “I would definitely use it again”. Some participants who vaped were not overly positive but said they “could probably get used to it” (P016V) or “could probably firm it out and get used to it after a week or two but I wouldn’t enjoy myself for that week” (P017V).

Some participants who vaped commented on the use of unflavoured e-liquids to stop vaping or using nicotine products entirely. If P006V were using e-cigarettes to “withdraw from nicotine completely then […] I could see like a chemist giving [unflavoured e-liquid] out for example, because there’s not much enjoyment to it.” P015V said, “I’d say it’s quite likely [I would use unflavoured e-liquid again] because I don’t think I’m ever gonna get off vaping completely if I’m having things that are really nice” and P009V said “if I wanted to stop vaping maybe I should stop making it taste like Eton mess [a dessert containing cream, meringue and fruit.]” P020V said unflavoured e-liquid “is a good way to maybe completely get rid of all type of nicotine products because it would put you off in a way […] but, I mean I genuinely would rather have a cigarette.” Not all participants who vaped said that unflavoured e-liquids are useful for stopping vaping. P014V said “unflavoured liquid wouldn’t really help me in any way to, to stop vaping because I’m still gonna crave that nicotine hit, you know? If I wanted to stop vaping, I would have to use patches.” P018V said, “if I was to wean myself off vaping, I’d probably try and do it with one with maybe like no nicotine in, […] but I would still go for a flavoured one, I wouldn’t want the unflavoured.”

Many participants who vaped reported that they used their e-cigarette less than usual while using the unflavoured e-liquid. P004V thought during the 4-h trial period they “vaped like nowhere near as much as I usually would in this time. Just because I think it wasn’t like as much fun” and P006V said, “I don’t really wanna use it.” P015V, P017V, P018V, P019V and P020V all thought that they vaped less than usual too, but P016V vaped “about the same” and P014V thought they vaped “a lot more” which they reported was “because [of] the lack of flavour, I wasn’t really getting the full satisfaction that I normally get, so I was constantly on it.”

Taste of unflavoured e-liquid and flavour preferences

Discussions of the taste of the unflavoured e-liquid and participants’ own preferences for specific flavours versus preferences among youth and those who do not smoke formed a superordinate theme. There was variety in the flavours that participants disliked or preferred and many described trialling different flavours when considering using e-cigarettes and during their transition from smoking to vaping. P010S said, “they’ve got all these flavours so let’s try them”, and P007V described a process of “trial and error” in finding the right flavour for them. Many participants who vaped preferred “primarily the fruit ones” (P004V), including one participant who initially assumed they “wouldn’t have flavoured liquids, because it doesn’t really mimic smoking” (P015V).

After trying the unflavoured e-liquid, some preferred it to flavours such as menthol or fruit/sweet flavours, but most preferred flavours. There were individual differences in which flavour participants stated they would choose if only tobacco, menthol or unflavoured e-liquids remained on the market; some stated tobacco, some stated menthol, and some stated unflavoured, but some, like P004V “would prefer to use cigarettes over [unflavoured e-liquid]”.

When prompted about the taste and flavour of the unflavoured e-liquid, some participants described it as “unflavoured”, “plain”, like “water” whereas some described a “metallic” or “burnt” taste, and some reported a hint of “sweetness”.

Many participants found the variety of flavours appealing when they initially decided to vape, and some participants who smoked also discussed the appeal. P014V found the variety of flavours available “extremely appealing”, P015V found “the variety quite helpful”, and P017V said “there’s like so many different flavours and there’s like you can have anything you want pretty much” which “hundred percent” influenced their decision to vape and made switching from smoking to vaping a “smoother transition”. The appeal of flavours persuaded P013V to make the switch due to the “nice smells”. P024S thought they “would prefer vaping if it was flavoured.” Some participants thought flavours also appealed to children and people who do not smoke. P016V believed “like the strawberry cheesecake ones […] they’d definitely appeal to younger kids. I reckon that’s probably what they would smoke if they did smoke them” and P020V thought “a hundred percent, yeah, I think it does create an appeal [to people who do not smoke]”. Not all participants found vaping appealing (e.g., P002S found flavours “too sweet”) and not all participants said that flavours appealed to children either. P025S disagreed with the argument that “because they’re young, they must go for fruit stuff” and said “it’s more the adults that go for it, strangely enough, because it reminds them of their childhood.”

Personal impact of a hypothetical flavour ban (excluding tobacco and menthol)

Some participants, particularly those who smoked, were confident a ban on flavoured e-liquids (whereby unflavoured, tobacco flavoured, and menthol flavoured e-liquids would remain on the market) would not personally affect them. P011S said, “for people like me, you know smokers, it wouldn’t bother me too much”. P008S said, “I could still erm use them to quit” but thought “it might not be as encouraging.” There were some participants who vaped, particularly those who enjoyed using the unflavoured e-liquid, who “would definitely keep to using [unflavoured e-liquid], because it’s not harsh” (P013V). Some participants who vaped, like P016V, did not feel their quit attempt would have been hampered in this scenario: “I do think I would [have successfully quit using an e-cigarette], because you still get the hit off it […] I think if I hadn’t tried flavoured, I wouldn’t know any different.” Some participants’ confidence that they would not be affected by flavour restrictions seemed to stem from their commitment to never smoke again: “I’m definitely out of that habit, I never, never want to go back to that habit again” (P014V). Some felt that “enough time has passed” since quitting that they may be able to cope with the change (P007V). One participant discussed continuing to make their own flavours if “ingredients were still available” (P007V).

Some participants reported that they would be negatively impacted by flavour restrictions. Some who smoked thought that they would not attempt to quit: “if it was only unflavoured, I probably wouldn’t bother” (P003S). A few participants who vaped suggested that they may have never tried to quit smoking in this scenario, for example P006V said “I probably wouldn’t of bothered stopping smoking if that had been the case.” Whereas some said they would have tried vaping but “might not […] have been as successful at stopping smoking” (P014V). Some participants who vaped thought they would return to smoking like P019V who would try “whatever was available… for a while, but then I, I think I’d probably go back to smoking”. Some participants who vaped “would just look towards quitting” nicotine products entirely (P017V). A few participants who vaped thought that a flavour restriction would cause them to vape less, like P004V, who did not think they “would vape nearly as much”. Some participants who vaped reported that they would try to access flavoured e-liquids illegally like P015V, who said “I would try and get it elsewhere if I was really motivated […] depends on how far along I was that I wanna quit, but at this stage now, I would probably get it elsewhere somehow.”

Although some participants supported a restriction on flavoured e-liquids in the UK, none stated personal reasons for this. Many stated personal reasons for a ban in the UK being a “bad idea”. When asked if flavours should be banned in the UK, P018V said, “because I vape and I vape the flavoured ones, I would say no.” Some thought we should not “be attacking what’s been like a really good way to get people to quit smoking and use something healthier” (P002S). Others thought that people “should have a choice. It’s up to people to choose to do possibly unhealthy things if they want to” (P024S). P009V said, “selfishly I don’t want it to happen because I like Eton mess”, which echoed comments from other participants who did not want their favourite flavours to be removed. Some participants would only be in support of a ban if “a causal link has been established between [flavourings and] negative health outcomes” (P007V). P016V thought “you could find it if you wanted it” even if the flavours were banned. Many suggested that they would be more supportive of other restrictions and regulations over banning flavours except from menthol and tobacco; instead of “command and control, […] monitoring it and regulating it” (P011S). The alternative policies suggested by the participants included adding age restrictions, stricter age verification, reducing appeal of packaging, restricting only some flavours which most appeal to youth, and better marketing restrictions.

Impact of a hypothetical flavour ban on others (excluding tobacco and menthol)

Although participants did not see a personal benefit resulting from restricting non-tobacco flavoured e-liquids, some participants thought the hypothetical favour ban would benefit youth as they thought some flavours may appeal to children. P015V thought some flavours should be banned because “strawberry laces, and things like that, that’s just screaming to children, to me”. P003S thought: “I see a lot of young people vaping. So, I do think that removing them from the market probably would help that, and I don’t think any kid would think it’s very cool to be puffing on an unflavoured liquid.” P004V spoke of friends who “didn’t really smoke and then they started vaping like a lot just because it tastes nice and like it’s something to fiddle with and it gives you like a niccy rush and like serotonin rush” and thought a flavour ban “would definitely be a good idea.” P021S thought that “popular vape companies are aware of that these sort of e-liquids are attractive for young children” and thought “it should be banned if it’s something that’s getting out of control.”

Many participants thought that the benefit to youth did not outweigh the benefit to adults who smoke or vape who could use these flavours to refrain from smoking, and some thought less harmful alternatives to smoking should be promoted rather than discouraged. P002S said “the benefits [of flavour availability] probably outweigh the risks” and that vaping has “helped a lot of people quit and [a number of people] demonstrably higher than sort of any number you could conjure up of people who have taken up smoking off the back of sort of starting with flavoured e-liquid from when they were young.” P019V wondered “are more people smoking now, [in countries which have restricted flavours], because they haven’t got the option to vape? Or what they want to vape, the flavours they want to vape?” P007V thought “it wouldn’t be helpful” and “it would slow down the rate of people that are quitting smoking.” Although they “wouldn’t want young people to start to vape” they would “want people who smoke to, to do whatever it takes to stop smoking and […] if they’re like me, then vaping’s been the only thing […] that’s made that possible, so I would want to give everyone else the opportunity to do that too.” P011S thought “stopping young people from smoking is great for future generations” but “the focus should also be on current smokers, to stop them from smoking and try and find an alternative means.” P015V thought that restricting all flavours could lead to increased “criminality” and highlighted that any new policy “needs to be safe, ‘cause if they ban it completely then they’ll just open it up for things to become very unsafe” for people who use e-cigarettes.

Not all participants said that the hypothetical restrictions would be beneficial to youth either, primarily because they thought it would be ineffective in preventing vaping among youth. P023S thought the more you tell young people “they can’t do something, the more they’re likely to do it if anything.” P024S said, “if kids wanna do something a bit rebellious or something they’re not meant to do, they’re gonna do it anyway.” They said when they “first started smoking when I was 13… I just did it, I didn’t go for the flavoured products, I just used the regular ones because my friends were doing it.” P025S thought that youth today are “social media’s [generation] not the candyfloss generation. So, I don’t think it matters whether you stop fruit.” They thought if we keep associating flavours like “bubblegum and candyfloss with just kids, then that works for the younger kids in that generation of like toddlers […] but, I think for the younger teens… most of the stuff the parents think [they haven’t] tried, they probably have.” They said, “I don’t think if you ban it, it will stop anything. They will just go for the next thing that’s available.” P010S said, “you’re not going to stop young people from experimenting with tobacco or anything, so, […] they would probably find something that… had a flavour… that… in my guess would be some weed.”

Some participants thought that restrictions would be ineffective, particularly if the aim was to prevent youth from smoking, as they were sceptical about the gateway hypothesis. P002S was “sort of sceptical of the sort of like gateway argument” because “the flavour of flavoured e-liquid is so drastically different to the actual flavour of tobacco.” They said, “if the only options are tobacco flavoured, then they’re more likely to find the adjustment to… actually going onto smoking” easier. P019V thought “vaping is definitely more appealing than smoking, but then I can’t imagine why people would start smoking after trying vaping”. P011S said that it is hard to generalise, it is not that “they have one puff on this flavoured e-cigarette and that’s it, they’re hooked, they’re a smoker, and you know… it’s all going to go downhill from there. That’s… that’s not the case.” P008S said “it does the opposite” and they knew “a lot of people that it has helped […]. Some of them have quit [smoking].” The experience of P017V was more in line with the gateway hypothesis; they “didn’t really smoke” and tried vaping because it was “nicer”, “different”, “socially acceptable” and potentially less harmful than smoking. They then went through a “cycle of smoking, vaping” and were supportive of a ban on flavours to protect youth from smoking.

Some participants suggested alternative actions to take instead of restricting flavours. P021S suggested increasing awareness that the product is not for young people, but they thought a ban should only be considered “if it definitely would help kind of cut down the numbers of children vaping.” P022S suggested using social media to discourage youth vaping alongside other methods because youth vaping is “a really complex problem, hence it requires a complex solution.” Others thought we should use existing regulations for other products as a guide. P007V thought “regulations around smoking are more or less appropriate” and they “should be similar for vaping.” P017V compared vaping regulations to alcohol regulations: “when you buy alcohol and stuff and it’s delivered, they like check your ID at the door, rather than just handing over like a crate of wine to a ten-year-old.” They went on to compare vaping to gambling, “like betting on your phone, you have to go send your ID off, and your driving licence off and it has to be linked to your bank account, so, it’s definitely you. Why can similar things not be put in place for buying alcohol, tobacco products?”.

Other drivers of vaping behaviour are more important than flavours

Participants identified other drivers of vaping behaviour they thought were more important than flavours in the appeal and use of e-cigarettes (with respect to themselves or others). P007V said, flavours did not impact the reason they started smoking so they “would be surprised if flavour alone was influencing young people deciding to start vaping.” The most common driver of vaping behaviour that participants thought was more important than flavours was nicotine. Like many others, P014V was “vaping to get the nicotine hit […] the flavours just a bonus really.” P025S said, “flavours isn’t the issue, because it’s the nicotine that’s the issue. […]. There’s flavours out there now, but… that’s not what’s causing the young people to try it.”

Health concerns (e.g., considering the comparative health risks and benefits of vaping compared to smoking) were prominent in the decision-making process of whether to use e-cigarettes or not for some participants. P001S was wary about e-cigarette use and “read loads of articles saying that they like […] don’t really understand them” which “scared” them. P020V said “there’s still risks to vaping, but nowhere near as bad as smoking.” P013V vaped because they “just thought it’s got to be healthier for you than smoking.” Some stated that they would only stop using flavoured products or vaping if “some like scientific research was done, and it turned out that the flavoured ones are very, very bad for you. You know, as bad as smoking and they can damage the lungs whereas the unflavoured ones, is very minimal damage” (P014V). Some participants who smoked mentioned their concerns about the potential addictiveness of e-cigarettes which discouraged them from using e-cigarettes. For example, P012S was wary that “if I did put a flavour in here, my consumption would very much, like, increase from it” because the unflavoured e-liquid was “not that pleasant to do, but it still has the addictive quality. Whereas if it was pleasant to do, and had the addictive quality” they would use it more. Some thought health concerns could feed into the decisions young people make too. P010S thought “young people these days […] tend to be a lot healthier” and would therefore be more wary of trying e-cigarettes. Some thought that the lesser health risks were reason to not be concerned if youth vaped instead of smoked. P002S said, “I don’t believe that there’s a lot of people that are picking up sort of e-cigarettes just because it’s flavoured” and if they were “there’s not much reason to believe it’s […] that harmful to health and if it is then it’s certainly most likely less harmful than if they were to pick up smoking.”

More often, however, participants thought the trendiness of e-cigarettes and peer pressure were the biggest drivers influencing e-cigarette use among young people. P001S suggested “it probably is just because they are sweet and then they look cooler or something.” P019V proposed people who do not smoke vape because “it’s like a peer pressure thing” and P025S said: “this is the social media generation, so, everything’s a hype” so young people will do “whatever they see the celebrities do” and “the celebrities don’t look like they’re stopping anytime soon. So, it’s the new thing.” P022S recalled that after watching films and TV, “seeing imagery of people smoking […] to some extent just subconsciously I started mimicking them in some way and I haven’t really seen anyone vaping.” P023S suggested “there should be [senior male celebrity] on the BBC smoking flavoured vapes to make it as uncool as possible” to discourage youth use. Other drivers of vaping behaviour discussed included the ease of vaping, cost of vaping, the social acceptability, the effectiveness of the device, to get breaks at work, behavioural aspects, and peer pressure (Additional file 1 , Sect. 2.2).

This study provides an insight into the potential impact of e-liquid flavour restrictions in the UK. At a time when there is considerable pressure on the UK government to address the rise in e-cigarette use among young people, this study indicates the impact of a flavour ban from the perspectives of people who have used and could use e-cigarettes to quit smoking. When making policy decisions, it is important to consider evidence such as this to avoid negative consequences and increase the likelihood of the policy reducing population-level harm. We found six superordinate themes which centred around the intentions and motivations to stop smoking and vaping, the sensations and experience of vaping unflavoured e-liquid, the taste of unflavoured e-liquid and flavour preferences, the negative impact of flavour restrictions on the participants, the positive and negative impact of flavour restrictions on others, and other drivers of behaviour being more important than flavours.

Our findings are consistent with previous evidence suggesting that the experiential aspects of e-liquids are important and could influence behaviour. For example, the harshness of the unflavoured e-liquid was discussed by participants. Previous research has shown that harshness of e-liquids is a quality that is disliked by people who use e-cigarettes [ 29 ], but throat hits can be pleasant or unpleasant for people who smoke, and finding the optimal throat hit is associated with increased desire to quit smoking using e-cigarettes [ 16 ]. Our results suggest unflavoured e-liquids may be too harsh for people who use e-cigarette who have adjusted to less harsh, flavoured e-liquids and not harsh enough for some people who smoke who enjoy a strong throat hit. The unflavoured e-liquid was sufficient to satisfy some participants’ cravings for nicotine and cigarettes, as we have found previously [ 18 ], but they were not as enjoyable for some who currently use flavoured e-liquids. Some participants felt that the switch from smoking to vaping was made easier because of the similarities between the two behaviours, but the desire to mimic cigarettes may decrease over time. Some participants who smoked had tried vaping but stopped because the flavour differed from smoking, whereas those who continued to vape seemed to prefer there to be a difference in flavour. When initially quitting, similarity to smoking and tobacco flavour may be important, but Farsalinos et al. [ 19 ] found that flavour variability is very important to people who use e-cigarettes who have successfully stopped smoking. In line with our findings, other research has shown people who smoke report using a preferred flavour when starting to vape, which may take some trial and error to find, but some people continue to seek variety [ 8 ] and many people who vape regularly use multiple flavours [ 17 , 43 , 44 ]. Our survey results support this, with most participants reporting using a variety of flavours rather than one specific flavour (Additional file 2 : Table S5). Some participants who vaped claimed they vaped less than they usually would when using the unflavoured e-liquid provided. Infrequent vaping is associated with greater risk of relapsing to smoking compared to frequent vaping [ 10 ], so changes in frequency of use due to flavour restrictions could impact the likelihood of relapse to smoking.

As suggested by many of the participants, current evidence suggests that flavours other than tobacco and menthol appeal to non-smoking young people as well as adults who smoke and/or vape [ 30 , 35 , 36 ], but the participants raised many potential issues that could arise from a restriction on e-liquid flavours which could ultimately result in increased population-level harm. One potential issue raised was that the restrictions may lead more people to start or continue to smoke cigarettes. Consistent with this perception, flavour restrictions in San Francisco were reportedly followed by reductions in e-cigarette use but increases in smoking among young adults [ 22 , 54 ]. Buckell et al. [ 12 ] found that while flavour restrictions could reduce choice of e-cigarettes by 11% they could also increase choice of cigarettes by 8% among people who smoke or have recently quit. Another potential issue was that some thought they would make their own e-liquids or obtain them illegally, which reflects what occurred in Finland, where 43% of people who vaped in the year after flavour restrictions were introduced used banned flavours [ 42 ]. The use of illicit and adulterated e-cigarette products, and products from informal sources can expose people to additional harms: 2,807 people were hospitalised, and 68 people were killed during the e-cigarette and vaping associated lung injury (EVALI) outbreak (July 2019 to February 2020), when vitamin E acetate was added to e-cigarettes to vape Delta-9-tetrahydrocannabinol [THC] instead of nicotine [ 9 ]. For these reasons, some participants did not think flavours being restricted in the UK was a good idea, in line with survey data from the International Tobacco Control (ITC) study which found that a ban on non-tobacco flavours would be strongly opposed by more than 81% of people who vape [ 26 ].

Despite the potential issues raised, some participants were still supportive of flavour restrictions to discourage youth from initiating vaping. In line with these participants’ opinions, after flavour restrictions were introduced in Finland, e-cigarette use has remained low among 15- to 69-year-olds [ 42 ], and the prevalence of e-cigarette use among young adults has decreased among young adults since the ban in San Francisco and other US states [ 13 , 54 ]. Other participants suggested that alternative measures could be more effective, and that there are other more important drivers of vaping behaviour than flavours, such as health concerns and trendiness. The alternative measures suggested, such as increased age restrictions and stricter marketing regulations, have been implemented in other countries with varying success [ 53 ]. Patel et al. [ 37 ] found 85% of US adults who vape cited health and smoking cessation as a reason for using e-cigarettes, 57% cited convenience, and 34% cited flavouring. Although younger adults (18–24 years) were more likely to cite flavours (46%) than the older adults, they were more likely to report health/cessation (73%) and convenience (55%) as reasons for use [ 37 ]. In UK adults, a reduction in beliefs that e-cigarettes are less harmful than combustible cigarettes was associated with a decrease in the prevalence of e-cigarette use. Trendiness has also been reported to influence youth use both in the UK and US in qualitative interviews with youth [ 11 , 49 ].

This study allowed us to explore various experiences and opinions from people of different ages (19–62 years) and people with different smoking and vaping histories, however, the participants were predominantly White. We acknowledged that few people who vape in the UK use unflavoured e-liquids, so participants tried an unflavoured e-liquid before commenting on flavour restrictions that would exclude unflavoured e-liquids.

Although participants were allowed to trial the unflavoured e-liquid for 4 h, taste profiles can change after stopping smoking, so the findings may have been impacted by the short trial period as well as the lack of tobacco and menthol e-liquid provision, the use of unfamiliar devices, and potential device malfunctions. Participants who smoked were only offered unflavoured e-liquid and not flavoured e-liquid and they did not receive a live demonstration or live advice on how to use the e-cigarette, which could have influenced their responses. Although eight out of twelve of these participants had tried vaping (and had likely experienced flavoured e-liquids before), the inhalation processes can considerably differ between smoking and vaping with increased experience [ 20 ], so participants may have had a more positive experience with further guidance on how to use the product. These findings are reflective of the participants subjective estimation of the impact of a hypothetical restriction rather than an objective observation of the impact, and the research was conducted before the UK government announced plans to restrict flavours. Future research could explore the potential impact of other restrictions which have been announced by the UK government, such as restricting the sale of disposable e-cigarettes, to identify which regulations may have the least negative impact on people who currently smoke and vape. The impact of unflavoured versus flavoured e-liquids on vaping frequency and smoking cessation could also be explored.

In conclusion, there are differences in how individuals who smoke or vape perceived they may be impacted by e-liquid restrictions in the UK. Some believed they would be unaffected as they would use unrestricted flavours or continue to smoke, but some felt they would be at greater risk of relapsing to smoking or continuing smoking rather than quitting with an e-cigarette. Most participants seemed to support the prevention of young people from starting to vape, but they had differing opinions on whether restricting flavours would be an effective method to discourage youth vaping. These results reflect participant perceptions of the impact of a flavour ban, but actual behaviour in the event of a restriction may differ. Nevertheless, the subthemes identified here could be used to guide further research into the impact of flavour restrictions which could be used to aid policy decisions to reduce harm related to smoking and vaping.

Availability of data and materials

Data are available at the University of Bristol data repository, data.bris, at https://doi.org/10.5523/bris.1hr9weuiqmiq52344a0wczg00i .

Abbreviations

British Broadcasting Company

Cigarettes per day

Electronic Cigarettes

Interpretative Phenomenological Analysis

International Tobacco Control

Propylene glycol

Tobacco and Alcohol Research Group

United Kingdom

United States

United States of America

Universal Serial Bus

Vegetable glycerin

Abrams DB, Niaura R, Brown RA, Emmons KM, Goldstein MG, Monti PM. The Tobacco Treatment Handbook: A Guide to Best Practices. New York: Guildford Press; 2003.

Google Scholar  

Action on Smoking and Health. (2020). Use of e-cigarettes (vapes) among adults in Great Britain . https://ash.org.uk/wp-content/uploads/2020/10/Use-of-e-cigarettes-vapes-among-adults-in-Great-Britain-2020.pdf

Action on Smoking and Health. (2021). Use of e-cigarettes (vapes) among adults in Great Britain. . https://ash.org.uk/wp-content/uploads/2021/06/Use-of-e-cigarettes-vapes-among-adults-in-Great-Britain-2021.pdf

Action on Smoking and Health. (2023). Use of e-cigarettes (vapes) among adults in Great Britain . https://ash.org.uk/uploads/Use-of-e-cigarettes-among-adults-in-Great-Britain-2023.pdf?v=1691058248

Adermark L, Galanti MR, Ryk C, Gilljam H, Hedman L. Prospective association between use of electronic cigarettes and use of conventional cigarettes: a systematic review and meta-analysis. ERJ Open Research. 2021;7(3):00976–2020. https://doi.org/10.1183/23120541.00976-2020 .

Article   PubMed   PubMed Central   Google Scholar  

Beard E, Brown J, Shahab L. Association of quarterly prevalence of e-cigarette use with ever regular smoking among young adults in England: a time–series analysis between 2007 and 2018. Addiction. 2022;117(8):2283–93. https://doi.org/10.1111/add.15838 .

Benowitz NL, Hukkanen J, Jacob P 3rd. Nicotine chemistry, metabolism, kinetics and biomarkers. Handb Exp Pharmacol. 2009;192:29–60. https://doi.org/10.1007/978-3-540-69248-5_2 .

Article   CAS   Google Scholar  

Blank M-L, Hoek J. Choice and variety-seeking of e-liquids and flavour categories by New Zealand smokers using an electronic cigarette: a longitudinal study. Nicotine Tob Res. 2020;23(5):798–806. https://doi.org/10.1093/ntr/ntaa248 .

Article   PubMed Central   Google Scholar  

Blount BC, Karwowski MP, Shields PG, Morel-Espinosa M, Valentin-Blasini L, Gardner M, Braselton M, Brosius CR, Caron KT, Chambers D, Corstvet J, Cowan E, De Jesús VR, Espinosa P, Fernandez C, Holder C, Kuklenyik Z, Kusovschi JD, Newman C, Pirkle JL. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. New England J Med. 2019;382(8):697–705. https://doi.org/10.1056/NEJMoa1916433 .

Article   Google Scholar  

Brose LS, Bowen J, McNeill A, Partos TR. Associations between vaping and relapse to smoking: preliminary findings from a longitudinal survey in the UK. Harm Reduct J. 2019;16(1):76. https://doi.org/10.1186/s12954-019-0344-0 .

Brown R, Bauld L, de Lacy E, Hallingberg B, Maynard O, McKell J, Moore L, Moore G. A qualitative study of e-cigarette emergence and the potential for renormalisation of smoking in UK youth. Int J Drug Policy. 2020;75:102598. https://doi.org/10.1016/j.drugpo.2019.11.006 .

Article   CAS   PubMed   PubMed Central   Google Scholar  

Buckell J, Marti J, Sindelar JL. Should flavours be banned in cigarettes and e-cigarettes? Evidence on adult smokers and recent quitters from a discrete choice experiment. Tob Control. 2019;28(2):168–75. https://doi.org/10.1136/tobaccocontrol-2017-054165 .

Cadham CJ, Liber AC, Sánchez-Romero LM, Issabakhsh M, Warner KE, Meza R, Levy DT. The actual and anticipated effects of restrictions on flavoured electronic nicotine delivery systems: a scoping review. BMC Public Health. 2022;22(1):2128. https://doi.org/10.1186/s12889-022-14440-x .

Chen G, Rahman S, Lutfy K. E-cigarettes may serve as a gateway to conventional cigarettes and other addictive drugs. Adv Drug Alcohol Res. 2023. https://doi.org/10.3389/adar.2023.11345 .

Chen JC, Green K, Fryer C, Borzekowski D. Perceptions about e-cigarette flavors: a qualitative investigation of young adult cigarette smokers who use e-cigarettes. Addict Res Theory. 2019;27(5):420–8. https://doi.org/10.1080/16066359.2018.1540693 .

Dautzenberg B, Scheck A, Kayal C, Dautzenberg M-D. Assessment of throat-hit and desire to switch from tobacco to e-cigarette during blind test of e-liquid and e-cigarette. Eur Respir J. 2015;46(suppl 59):280. https://doi.org/10.1183/13993003.congress-2015.OA280 .

Diamantopoulou E, Barbouni A, Merakou K, Lagiou A, Farsalinos K. Patterns of e-cigarette use, biochemically verified smoking status and self-reported changes in health status of a random sample of vapeshops customers in Greece. Intern Emerg Med. 2019;14(6):843–51. https://doi.org/10.1007/s11739-018-02011-1 .

Article   PubMed   Google Scholar  

Dyer ML, Khouja JN, Jackson AR, Havill MA, Dockrell MJ, Munafo MR, Attwood AS. Effects of electronic cigarette e-liquid flavouring on cigarette craving. Tob Control. 2021. https://doi.org/10.1136/tobaccocontrol-2021-056769 .

Farsalinos KE, Romagna G, Tsiapras D, Kyrzopoulos S, Spyrou A, Voudris V. Impact of flavour variability on electronic cigarette use experience: an internet survey. Int J Environ Res Public Health. 2013;10(12):7272–82. https://doi.org/10.3390/ijerph10127272 .

Farsalinos KE, Spyrou A, Stefopoulos C, Tsimopoulou K, Kourkoveli P, Tsiapras D, Kyrzopoulos S, Poulas K, Voudris V. Nicotine absorption from electronic cigarette use: comparison between experienced consumers (vapers) and naïve users (smokers). Sci Rep. 2015;5(1):11269. https://doi.org/10.1038/srep11269 .

Foulds J, Veldheer S, Yingst J, Hrabovsky S, Wilson SJ, Nichols TT, Eissenberg T. Development of a questionnaire for assessing dependence on electronic cigarettes among a large sample of ex-smoking E-cigarette users. Nicotine Tobacco Res. 2015;17(2):186–92. https://doi.org/10.1093/ntr/ntu204 .

Friedman AS. A difference-in-differences analysis of youth smoking and a ban on sales of flavored tobacco products in San Francisco. California JAMA Pediatrics. 2021;175(8):863–5. https://doi.org/10.1001/jamapediatrics.2021.0922 .

Gades MS, Alcheva A, Riegelman AL, Hatsukami DK. The role of nicotine and flavor in the abuse potential and appeal of electronic cigarettes for adult current and former cigarette and electronic cigarette users: a systematic review. Nicotine Tobacco Res. 2022;24(9):1332–43. https://doi.org/10.1093/ntr/ntac073 .

Gibson MJ, Munafò MR, Attwood AS, Dockrell MJ, Havill MA, Khouja JN. A decision aid for policymakers to estimate the impact of e-cigarette flavour restrictions on population smoking and e-cigarette use prevalence among youth versus smoking prevalence among adults. medRxiv. 2023. https://doi.org/10.1101/2022.11.14.22282288 .

Gravely S, Meng G, Hammond D, Hyland A, Michael Cummings K, Borland R, Kasza KA, Yong H-H, Thompson ME, Quah ACK, Ouimet J, Martin N, O’Connor RJ, East KA, McNeill A, Boudreau C, Levy DT, Sweanor DT, Fong GT. Differences in cigarette smoking quit attempts and cessation between adults who did and did not take up nicotine vaping: Findings from the ITC four country smoking and vaping surveys. Addict Behav. 2022;132:107339. https://doi.org/10.1016/j.addbeh.2022.107339 .

Gravely S, Smith DM, Liber AC, Cummings KM, East KA, Hammond D, Hyland A, O’Connor RJ, Kasza KA, Quah ACK, Loewen R, Martin N, Meng G, Ouimet J, Thompson ME, Boudreau C, McNeill A, Sweanor DT, Fong GT. Responses to potential nicotine vaping product flavor restrictions among regular vapers using non-tobacco flavors: findings from the 2020 ITC Smoking and Vaping Survey in Canada, England and the United States. Addict Behav. 2022;125:107152. https://doi.org/10.1016/j.addbeh.2021.107152 .

Kennedy RD, Awopegba A, De León E, Cohen JE. Global approaches to regulating electronic cigarettes. Tob Control. 2017;26(4):440–5. https://doi.org/10.1136/tobaccocontrol-2016-053179 .

Khouja JN, Wootton RE, Taylor AE, Davey Smith G, Munafo MR. Association of genetic liability to smoking initiation with e-cigarette use in young adults: a cohort study. PLoS Med. 2021;18(3): e1003555. https://doi.org/10.1371/journal.pmed.1003555 .

Kim H, Lim J, Buehler SS, Brinkman MC, Johnson NM, Wilson L, Cross KS, Clark PI. Role of sweet and other flavours in liking and disliking of electronic cigarettes. Tob Control. 2016;25(Suppl 2):55–61. https://doi.org/10.1136/tobaccocontrol-2016-053221 .

Krüsemann EJZ, van Tiel L, Pennings JLA, Vaessen W, de Graaf K, Talhout R, Boesveldt S. Both nonsmoking youth and smoking adults like sweet and minty e-liquid flavors more than Tobacco Flavor. Chem Senses. 2021. https://doi.org/10.1093/chemse/bjab009 .

Lindson N, Butler AR, McRobbie H, Bullen C, Hajek P, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, et al. Electronic cigarettes for smoking cessation. Cochrane Database System Rev. 2024. https://doi.org/10.1002/14651858.CD010216.pub8 .

Marrocco A, Singh D, Christiani DC, Demokritou P. E-cigarette vaping associated acute lung injury (EVALI): state of science and future research needs. Crit Rev Toxicol. 2022;52(3):188–220. https://doi.org/10.1080/10408444.2022.2082918 .

McNeill A, Brose L, Calder R, Simonavicius E, Robson D. Vaping in England: an evidence update including vaping for smoking cessation, February 2021 (Vaping in England, Issue. 2021. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/962221/Vaping_in_England_evidence_update_February_2021.pdf

McNeill A, Simonavičius E, Brose L, Taylor E, East K, Zuikova E, Calder R, Robson D. Nicotine vaping in England: an evidence update including health risks and perceptions, 2022 (A report commissioned by the Office for Health Improvement and Disparities, Issue. 2022. https://assets.publishing.service.gov.uk/media/633469fc8fa8f5066d28e1a2/Nicotine-vaping-in-England-2022-report.pdf

Meernik C, Baker HM, Kowitt SD, Ranney LM, Goldstein AO. Impact of non-menthol flavours in e-cigarettes on perceptions and use: an updated systematic review. BMJ Open. 2019;9(10): e031598. https://doi.org/10.1136/bmjopen-2019-031598 .

Notley C, Gentry S, Cox S, Dockrell M, Havill M, Attwood AS, Smith M, Munafò MR. Youth use of e-liquid flavours—a systematic review exploring patterns of use of e-liquid flavours and associations with continued vaping, tobacco smoking uptake or cessation. Addiction. 2022;117(5):1258–72. https://doi.org/10.1111/add.15723 .

Patel D, Davis KC, Cox S, Bradfield B, King BA, Shafer P, Caraballo R, Bunnell R. Reasons for current E-cigarette use among U.S. adults. Prev Med. 2016;93:14–20. https://doi.org/10.1016/j.ypmed.2016.09.011 .

Pepper JK, Brewer NT. Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review. Tob Control. 2014;23(5):375–84. https://doi.org/10.1136/tobaccocontrol-2013-051122 .

Pullicin AJ, Kim H, Brinkman MC, Buehler SS, Clark PI, Lim J. Impacts of nicotine and flavoring on the sensory perception of e-cigarette aerosol. Nicotine Tobacco Res. 2020;22(5):806–13. https://doi.org/10.1093/ntr/ntz058 .

Qualtrics. (2005). Qualtrics. https://www.qualtrics.com

Romm KF, Henriksen L, Huang J, Le D, Clausen M, Duan Z, Fuss C, Bennett B, Berg CJ. Impact of existing and potential e-cigarette flavor restrictions on e-cigarette use among young adult e-cigarette users in 6 US metropolitan areas. Prev Med Rep. 2022;28:101901. https://doi.org/10.1016/j.pmedr.2022.101901 .

Ruokolainen O, Ollila H, Karjalainen K. Correlates of e-cigarette use before and after comprehensive regulatory changes and e-liquid flavour ban among general population. Drug Alcohol Rev. 2022. https://doi.org/10.1111/dar.13435 .

Russell C, Haseen F, McKeganey N. Factors associated with past 30-day abstinence from cigarette smoking in a non-probabilistic sample of 15,456 adult established current smokers in the United States who used JUUL vapor products for three months. Harm Reduct J. 2019;16(1):22. https://doi.org/10.1186/s12954-019-0293-7 .

Russell C, Haseen F, McKeganey N. Factors associated with past 30-day abstinence from cigarette smoking in adult established smokers who used a JUUL vaporizer for 6 months. Harm Reduct J. 2019;16(1):59. https://doi.org/10.1186/s12954-019-0331-5 .

Shaw R, Burton A, Xuereb CB, Gibson J. Interpretative phenomenological analysis in applied health research . 2014. https://doi.org/10.4135/978144627305013514656

Smith JA, Fieldsend M.. Interpretative phenomenological analysis. In Qualitative research in psychology: Expanding perspectives in methodology and design, 2nd ed. (pp. 147–166). American Psychological Association. 2021. https://doi.org/10.1037/0000252-008

Smith M, Hilton S. Global regulatory approaches towards e-cigarettes, key arguments, and approaches pursued. In M. Dr. Allincia, P. S. Dr. Stanislaw, & I. Prof. Ricardo (Eds.), Global health security—contemporary considerations and developments (pp. Ch. 1). IntechOpen. 2022. https://doi.org/10.5772/intechopen.107343

Tindle HA, Shiffman S. Smoking cessation behavior among intermittent smokers versus daily smokers. Am J Public Health. 2011;101(7):e1–3. https://doi.org/10.2105/ajph.2011.300186 .

Tokle R. ‘Vaping and fidget-spinners’: A qualitative, longitudinal study of e-cigarettes in adolescence. Int J Drug Policy. 2020;82:102791. https://doi.org/10.1016/j.drugpo.2020.102791 .

Vasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. 2018;18(1):148. https://doi.org/10.1186/s12874-018-0594-7 .

Vennemann MM, Hummel T, Berger K. The association between smoking and smell and taste impairment in the general population. J Neurol. 2008;255(8):1121–6. https://doi.org/10.1007/s00415-008-0807-9 .

Weng X, Song CY, Liu K, Wu YS, Lee JJ, Guo N, Wang MP. Perceptions of and responses of young adults who use e-cigarettes to flavour bans in China: a qualitative study. Tob Control. 2024. https://doi.org/10.1136/tc-2023-058312 .

Yan D, Wang Z, Laestadius L, Mosalpuria K, Wilson FA, Yan A, Lv X, Zhang X, Bhuyan SS, Wang Y. A systematic review for the impacts of global approaches to regulating electronic nicotine products. J Glob Health. 2023;13:04076. https://doi.org/10.7189/jogh.13.04076 .

Yang Y, Lindblom EN, Salloum RG, Ward KD. The impact of a comprehensive tobacco product flavor ban in San Francisco among young adults. Addict Behav Rep. 2020;11:100273. https://doi.org/10.1016/j.abrep.2020.100273 .

Zoom Video Communications Inc. (2016). Security guide . Zoom Video Communications Inc. https://d24cgw3uvb9a9h.cloudfront.net/static/81625/doc/Zoom-Security-White-Paper.pdf

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Acknowledgements

We would like to acknowledge the work of two undergraduate students, Mollie Simmonds and Georgia Laidlaw, who provided input into the development of the study, were involved in data collection and assisted in the analysis of the data.

This work was supported by Public Health England (PHE) via an honorary contract awarded to AA. There is no grant number for this research as it was commissioned by Public Health England via the honorary academic framework. PHE were not involved in the conception or design of the study, data analysis or interpretation of the study findings. The MRC Integrative Epidemiology Unit (MRC IEU) at the University of Bristol provided wider support to this research (MC_UU_00011/7). This work was also supported by Cancer Research UK [Grant Number C18281/A29019].

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JK, MD, AA, and MM contributed to the development of the study protocol and study documents. With the assistance of two undergraduate students, JK conducted the qualitative interviews, transcribed the audio recordings, and coded the data. Disputes in the transcriptions or coding were resolved between the two students and JK. JK drafted the manuscript and all authors contributed to and approved the final manuscript.

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Khouja, J.N., Dyer, M.L., Havill, M.A. et al. Exploring the opinions and potential impact of unflavoured e-liquid on smoking cessation among people who smoke and smoking relapse among people who previously smoked and now use e-cigarettes: findings from a UK-based mixed methods study. Harm Reduct J 21 , 90 (2024). https://doi.org/10.1186/s12954-024-01003-z

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Feasibility of restricting e-cigarettes to prescription only for smoking cessation

• Katya Peri 1 &
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Respiratory Research volume  25 , Article number:  200 ( 2024 ) Cite this article

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E-cigarette use among youth in Canada has risen to epidemic proportions. E-cigarettes are also moderately useful smoking cessations aids. Restricting e-cigarettes to prescription only smoking cessation aids could help limit youth’s access to them while keeping them available as therapies for patients who smoke conventional cigarettes. In Canada, drugs or devices must be approved by regulatory bodies such as Health Canada in order to become licensed prescription medications. A similar situation is underway in Australia, where e-cigarettes have been restricted to prescription only. This commentary explores the feasibility of a similar regulation for e-cigarettes in Canada as prescription smoking cessation aids.

Introduction

E-cigarettes (ECs) are handheld electronic devices that heat liquids containing nicotine to administer aerosols to the user [ 1 ]. E-cigarettes deliver nicotine to the brain more rapidly than other nicotine replacement therapies (NRTs) and mimic the sensorimotor and behavioural aspects of smoking a conventional cigarette [ 2 ]. This has made them popular among smokers. It has also provided arguments for their use as a smoking cessation aid [ 2 ]. In addition, the use of e-cigarettes among youth has risen to epidemic proportions [ 3 ]. A concern is that there appears to be a correlation between EC use in youth and subsequent tobacco smoking, which leads to harmful health effects on children and their health [ 4 , 5 , 6 , 7 , 8 ]. Whether ECs act as a gateway to tobacco smoking remains to be clarified, however, the correlation between these behaviours warrants attention. To mitigate these effects, legislation should be enacted and enforced on the sales of e-cigarettes. In addition, even more restrictions could be enacted to ensure that e-cigarettes are only available via prescription as medically licensed smoking cessation aids. Restricting their distribution to prescription only will potentially provide a way to limit the use of e-cigarettes among youth, while providing access to smokers who are trying to quit smoking traditional cigarettes.

ECs as smoking cessation devices

A 2022 Cochrane review revealed that quit rates were superior in participants in the nicotine EC arm compared to the NRT arm (RR 1.63, 95% CI 1.30 to 2.04; I2 = 10%; 6 studies, 2378 participants) [ 9 ]. There is also evidence that ECs without nicotine improve quit rates compared to NRTs (RR 1.94, 95% CI 1.21 to 3.13; I2 = 0%; 5 studies, 1447 participants). A recent meta-analysis revealed that when used daily, ECs encouraged successful quitting (OR = 1.529; 95% CI = 1.158, 2.019; P  = .005) [ 10 ]. These results suggest that if ECs are used daily, they can be effective smoking cessation therapies. This manner of e-cigarette use can potentially be implemented if ECs are recognized as prescription only smoking cessation aids.

While a Cochrane review has revealed that the current body of literature is suggestive that ECs could be useful smoking cessation aids, the report also calls for additional research to form a concrete conclusion [ 9 ]. Additional research is required to confidently assess the efficacy and safety of ECs for smoking cessation. By performing knowledge syntheses as the number of clinical trials increases, researchers will be able to have a clearer picture of the benefits and harms of ECs.

ECs and youth

Despite their potential as a smoking cessation aid, e-cigarettes pose a risk to the health of youth. Among Canadian youth aged 15–17 years old, 21.3% reported e-cigarette use in 2022 [ 11 ]. Approximately 89% of youth aged 15–19 years old who reported using e-cigarettes within the last 30 days used e-liquid with nicotine [ 11 ]. Developmental deficits in memory and executive function as well as cognitive impairments with memory have been associated with early nicotine exposure [ 12 ]. Furthermore, youth who vape are also more likely to experiment with tobacco cigarettes compared to youth who do not vape. In a 2018 study published in JAMA, researchers found that youth who used e-cigarettes were 20.5% more likely to subsequently use a tobacco cigarette [ 13 ]. In Canada, 66% of youth who smoke tobacco cigarettes reported first experimenting with e-cigarettes [ 11 ]. Current interventions to prevent youth from using e-cigarettes include flavour bans, age restrictions, warning labels, e-cigarette taxes and mass media awareness campaigns [ 14 ]. Despite attempts at mitigating youth vaping by restricting sales to minors and enforcing these bans, the number of children and adolescents who vape is still at large proportions [ 15 ]. Restricting e-cigarettes to prescription only could potentially help decrease the number of children vaping and smoking.

EC regulation in Canada

Various legislative initiatives provide a legal framework for EC products in Canada. These initiatives are monitored for compliance and inspection by Health Canada. Regulation is primarily done under the Tobacco and Vaping Products Act (TVPA), however, the Canada Consumer Product Safety Act, the Food and Drug Act and the Non-smokers’ Health Act also make up the legal framework of EC regulation. However, it appears that the sales restrictions to minors may not be strictly enforced. To be considered licensed prescription medications, e-cigarettes must be approved as medical therapies [ 16 ]. Because the current body of evidence surrounding the long-term effects of e-cigarettes on patients’ health remains inconclusive, it is illegal to promote e-cigarettes as products that provide health benefits to their users [ 17 ]. In fact, EC packaging is required by law to include the following warnings “Vaping products contain nicotine, a highly addictive chemical” and “Vaping products release chemicals that may harm your health” [ 18 ]. Marketing ECs for smoking cessation or suggesting they are safer alternatives to tobacco cigarettes is therefore not allowed.

ECs as prescription smoking cessation aids

For ECs to be restricted as prescription smoking cessation aids in Canada, the health benefits of ECs as smoking cessation aids must be clearly shown to outweigh the risks. For this to happen, large-scale, trails that evaluate all varieties of potential ECs on the market must be conducted. These studies must conclude that ECs are beneficial as smoking cessation aids. Health Canada must then approve ECs for smoking cessation. This process involves gathering clinical evidence and determining that the therapeutic benefits of ECs as smoking cessation aids outweigh the risks. Amendments to the access, promotion and labelling sections of the TVPA, which “regulates the manufacture, sale, labelling and promotion of tobacco products and vaping products sold in Canada” would be required, as well as amendments to the Food and Drug Act. Specifications for the advertisement and promotion of ECs as drugs is required in the Food and Drug Act. Importantly, new laws or Acts of Parliament would be necessary to ban the commercial sale of ECs. To license their products as therapeutic devices, EC companies would have to submit the appropriate evidence proving their product falls under the category of smoking cessation aid as per the federal government’s new stipulations. Once approved, these ECs would be available in pharmacies only as prescription medications.

E-cigarettes present a unique dilemma: while they offer potential benefits distinct from traditional cigarettes, restrictions designed to manage their risks can inadvertently hinder access for those who stand to gain the most. Balancing these factors within regulatory frameworks is crucial. For instance, categorizing e-cigarettes as prescription devices could provide a middle ground, allowing for less restrictive regulations while still ensuring controlled access. This approach acknowledges the potential benefits of e-cigarettes while addressing concerns about their widespread availability and use.

EC use in Australia

One country Canada can potentially model its future EC regulatory framework from is Australia. In Australia, nicotine e-cigarettes are prescribed medicines and are only accessible from a doctor [ 19 ]. The Therapeutic Goods Administration (TGA) classifies nicotine used for non-therapeutic purposes as a dangerous poison (schedule 7 substance), restricting it to prescription only [ 20 ]. To ensure that the minimum quality and safety standards are met for nicotine e-cigarettes, the TGA has issued the Therapeutic Goods (Standard for Nicotine Vaping Products (TGO 110) Order 2021 [ 21 ]. Prescribers can access unapproved drugs via three pathways: the special access scheme, the personal importation scheme and the authorized prescriber scheme [ 22 ]. The guidelines of the Royal Australian College of General Practitioners (RACGP) state that nicotine containing e-cigarettes should not be used as a first line treatment for smoking cessation. They are only recommended for patients aged 18 years or older if conventional pharmacotherapies and interventions fail and the patient remains motivated to quit smoking.

EC use in the UK

Since EC restriction to prescription is unprecedented in North America, legislative and regulatory actions undertaken by other countries can serve as a model to follow. Canada can turn to its Commonwealth neighbour, England, for inspiration on how to implement EC restrictions to prescription only. In the UK, ECs have been endorsed by the UK Royal College of Physicians as acceptable smoking cessation aids. The National Institute of Health and Care Excellence has added ECs to the recommended list of smoking cessation therapies, mostly due to ECs being a safer alternative to tobacco smoking. A pilot project conducted in Greater Manchester involved the introduction of free ECs for smoking cessation in pharmacies. At the end of the study, 25% of smokers stopped using ECs and tobacco cigarettes after four weeks while 61% of those still smoking reduced their consumption by five cigarettes a day. In addition, the attitudes of both clients and service providers were mainly positive. This project is an example of the steps the UK is taking towards becoming smoke-free by 2030.

Although the UK does not have a prescription scheme like Australia does, the Medicines and Healthcare Products Regulatory Agency (MHRA) provides support and guidelines for companies wishing to license their ECs as medical devices. An application package including safety and quality evidence for both the medicinal product (e-liquid) and the device (pod/cigarette) must be approved in addition to non-clinical safety measures. Specifications standardizing the testing of the product must be met and statistical measurements of clinical variables (i.e. blood nicotine concentration) need to be approved. In addition, details regarding the manufacturing, packaging, processing and importation of these products are strictly monitored. With appropriate modifications, a similar regulatory framework could potentially be adopted in Canada. Restricting ECs to prescription only is feasible with the appropriate legislative and regulatory actions in place.

Feasibility of restricting ECs to prescription only in Canada

The feasibility of a Canadian model similar to Australia’s is relatively low and many barriers to their restriction as medical devices exist. The main barrier is that there is a lack of consensus as to the efficacy and safety of ECs. Compared to the NRTs that are currently available, ECs promote moderate rates of smoking cessation. However, Health Canada will not endorse the medical use of a product if their safety outcomes are unknown or significantly harmful to public health. Studies evaluating the safety of ECs are therefore required, in addition to those evaluating their efficacy as smoking cessation aids. Another significant barrier is that without proper evidence, the amendments to legislative acts regarding EC regulation are less feasible. Resistance at the level of primary care practitioners is also a barrier to making ECs prescription only. Studies have shown that physicians are reluctant to discuss the benefits and risks of ECs with their patients and are not convinced of their efficacy for smoking cessation or their safety [ 23 ]. Currently, EC regulatory documents, like the TGA, do not provide guidelines for physicians regarding dose, duration and type of EC. In addition to resistance at the clinical level, EC companies are not likely to pay for the extensive testing and certification process required to make their device a prescription medication. Restricting ECs to prescription only could at once provide the tobacco-smoking population with a useful cessation aid and curb the use of ECs in youth. In addition, the crux of the matter is not solely the consensus regarding effectiveness but rather the expenses, time investment, and intricacies involved in assembling product documentation and conducting clinical trials. Considering recent studies, it seems plausible for companies to navigate current regulations successfully. However, the challenge arises from the lack of motivation to undergo this costly process when there’s a simpler alternative: direct sales to consumers. Despite these significant benefits to public health, there exist significant barriers that would have to be overcome to implement this initiative.

As it stands, restricting ECs to prescription only is not currently feasible in Canada, mainly due to the lack of consensus surrounding the efficacy and safety of ECs as smoking cessation therapies. Despite this uncertainty, the research clearly shows ECs are a danger to youth. If ECs are eventually deemed safe and efficacious for smoking cessation, a major legislative overhaul of EC regulation would be needed to first suspend them for commercial use and limit them to prescription only. Limiting ECs to prescription only is a vital and delicate step that will require motivation and collaboration between governmental regulatory bodies, healthcare organizations and EC companies. Furthermore, it is unlikely that EC companies will be willing to financially support the testing and licensing procedures required to approve their products as medical devices. These procedures, although impractical, are not impossible and must be carefully considered with respect to existing models if the benefits to public health might outweigh the risks when it comes to prescription ECs. A regulatory framework similar to that of Australia could potentially benefit Canada in the fight against tobacco smoking.

Data availability

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Code availability

Dinakar C, O’Connor GT. The Health effects of Electronic cigarettes. N Engl J Med. 2016;375:1372–81.

Article   PubMed   Google Scholar  

DiPiazza J, Caponnetto P, Askin G, et al. Sensory experiences and cues among E-cigarette users. Harm Reduct J. 2020;17:75.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Fadus MC, Smith TT, Squeglia LM. The rise of e-cigarettes, pod mod devices, and JUUL among youth: factors influencing use, health implications, and downstream effects. Drug Alcohol Depend. 2019;201:85–93.

Article   PubMed   PubMed Central   Google Scholar  

Chan GCK, Stjepanović D, Lim C, et al. Gateway or common liability? A systematic review and meta-analysis of studies of adolescent e-cigarette use and future smoking initiation. Addiction. 2021;116:743–56.

Martinelli T, Candel M, de Vries H, et al. Exploring the gateway hypothesis of e-cigarettes and tobacco: a prospective replication study among adolescents in the Netherlands and Flanders. Tob Control. 2023;32:170–8.

Goldenson NI, Leventhal AM, Stone MD, McConnell RS, Barrington-Trimis JL. Associations of electronic cigarette nicotine concentration with subsequent cigarette smoking and vaping levels in adolescents. JAMA Pediatr. 2017;171:1192–9.

Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of Electronic Cigarette Use with Initiation of Combustible Tobacco Product Smoking in early adolescence. JAMA. 2015;314:700–7.

Chatterjee K, Alzghoul B, Innabi A, Meena N. Is vaping a gateway to smoking: a review of the longitudinal studies. Int J Adolesc Med Health 2016;30.

Hartmann-Boyce J, Lindson N, Butler AR, et al. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews; 2022.

Wang RJ, Bhadriraju S, Glantz SA. E-Cigarette use and adult cigarette Smoking Cessation: a Meta-analysis. Am J Public Health. 2021;111:230–46.

Rotermann M, Gilmour H. Correlates of vaping among adolescents in Canada. Health Rep. 2022;33:24–35.

PubMed   Google Scholar  

Tobore TO. On the potential harmful effects of E-Cigarettes (EC) on the developing brain: the relationship between vaping-induced oxidative stress and adolescent/young adults social maladjustment. J Adolesc. 2019;76:202–9.

Berry KM, Fetterman JL, Benjamin EJ, et al. Association of Electronic Cigarette Use with Subsequent Initiation of Tobacco Cigarettes in US youths. JAMA Netw Open. 2019;2:e187794.

Klein DE, Chaiton M, Kundu A, Schwartz R. A Literature Review on International E-cigarette Regulatory policies. Curr Addict Rep. 2020;7:509–19.

Article   Google Scholar  

Graham-DeMello A, Hoek J, Drew J. How do underage youth access e-cigarettes in settings with minimum age sales restriction laws? A scoping review. BMC Public Health. 2023;23:1809.

Drug products. 2022. at https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products.html .).

Tobacco and Vaping Products Act (S.C. 1997, c. 13). In: Canada H, ed.

Regulating tobacco and vaping products: Vaping products regulations. 2020. 2024, at https://www.canada.ca/en/health-canada/services/smoking-tobacco/vaping/product-safety-regulation.html#a2 .).

Nicotine Vaping. April. 2022. (Accessed 2022-11-17, 2022, at https://www.health.nsw.gov.au/pharmaceutical/Pages/nicotine-vaping.aspx#:~:text=From%201%20October%202021%2C%20consumers,the%20patient%20directly%20from%20overseas .).

Erku DA, Morphett K, Steadman KJ, Gartner CE. Policy debates regarding Nicotine Vaping products in Australia: a qualitative analysis of submissions to a Government Inquiry from Health and Medical Organisations. Int J Environ Res Public Health 2019;16.

Skerritt J. In: Health, Do, editors. Therapeutic Goods (Standard for Nicotine Vaping products) (TGO 110) Order 2021. Australian Government; May 2021.

Nicotine vaping products. Information for prescribers. Australian Government 2022. (Accessed November 17, 2022, at https://www.tga.gov.au/resources/resource/guidance/nicotine-vaping-products-information-prescribers .).

Selamoglu M, Erbas B, Kasiviswanathan K, Barton C. General practitioners’ knowledge, attitudes, beliefs and practices surrounding the prescription of e-cigarettes for smoking cessation: a mixed-methods systematic review. BMC Public Health. 2022;22:2415.

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Smoking during pregnancy may raise odds of overweight children

by Don Bell, University of Alberta

New research has turned up another reason for women to avoid smoking during pregnancy. A recent study published in the journal Gut Microbes has found an association between mothers smoking during pregnancy and a higher risk of their children becoming overweight or obese.

Childhood obesity is a growing concern globally, affecting more than 18% of children and adolescents aged 5 to 19 in 2020, a startling increase from just 4% back in 1975.

And it's a big problem. The study notes childhood obesity is linked to such negative outcomes as poorer health and lower self-esteem, and an increased likelihood of being bullied.

Anita Kozyrskyj, a microbiome epidemiologist and professor of pediatrics at the University of Alberta, is the co-senior author of the study. Kozyrskyj, who is a member of the Women and Children's Health Research Institute, has done a lot of research on early life factors that affect infant gut bacteria. These factors include how infants are born, how they're fed, the health of the mother and stress during her pregnancy .

Kozyrskyj says other researchers have shown that women who smoke during pregnancy tend to have babies who become overweight in childhood. But she says her group's study represents new ground because they show an association that might indicate the reason. And it's in those microbes found in the gut.

"We've known that for a long time. We just didn't know how it happened," Kozyrskyj says. "There may be many ways, but in our study, we showed one way is by changing the gut bacteria in the infant."

Kozyrskyj and the team used data from more than 1,500 children from the Canadian Healthy Infants Longitudinal Development (CHILD) Cohort. The team collected data from families that told about the mothers' environmental and lifestyle factors during pregnancy and those of their children from birth to age 3. Weight outcomes were measured at 1 and 3 years of age. Stool samples were collected at 3 and 12 months of age and analyzed to get a profile of the bacteria in them.

The researchers found that the increased risk of children being overweight and obese was associated with the amount and diversity of a phylum of bacteria known as Firmicutes. It was discovered that maternal smoking during pregnancy significantly increased the abundance of Firmicutes bacteria in the gut.

Breastfeeding helps

Kozyrskyj hastens to point out that Firmicutes are not a villain here. "It's not so much that these Firmicutes are bad bacteria, because they're required—a normal part of our gut bacteria ." What's different is that they are present in higher amounts in the guts of infants whose mothers smoked during pregnancy than in those of mothers who did not.

She adds, "These Firmicutes increase from soon after birth to later infancy. It's just that the increase (in infants of smoking mothers) occurred too soon. The amounts were too high."

Kozyrskyj explains that the excessive levels of Firmicutes can result in excessive production of butyrate, a short chain fatty acid.

"It's not like butyrate is poisonous or anything like that. It's a natural byproduct. We have butyrate levels in our intestines all the time," she says. But again, her team observed earlier and higher levels of butyrate among infants of smoking moms.

This study doesn't indicate a direct cause and effect between too much butyrate in infants and them becoming overweight, but rather an association. In an interesting twist, the association applied to those children even if their mothers reduced their intake or quit smoking part way through pregnancy.

The association was not present if mothers quit smoking before pregnancy. Something that ameliorated the smoking effect, however, was breastfeeding exclusively for the first 3 months of the baby's life.

Since the findings of the study are still associative, other studies would need to establish causality. But the implications are important, emphasizing the need for public health initiatives aimed at encouraging women to stop smoking before becoming pregnant.

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Association of Smoking During Pregnancy With Compromised Brain Development in Offspring

• 1 Department of General Practice, Institute of Medicine, University of Turku, Turku University Hospital, Turku, Finland
• Original Investigation Association of Maternal Tobacco Use During Pregnancy With Preadolescent Brain Morphology Runyu Zou, PhD; Olga D. Boer, MSc; Janine F. Felix, PhD; Ryan L. Muetzel, PhD; Ingmar H. A. Franken, PhD; Charlotte A. M. Cecil, PhD; Hanan El Marroun, PhD JAMA Network Open

The study by Zou et al 1 provides new insights into the association between maternal smoking during pregnancy and offspring brain development in preadolescence. The study is part of the Generation R Study, a prospective population-based cohort study in Rotterdam, the Netherlands. The present study included a total of 2704 singleton children, of whom 2102 (77.7%) were unexposed, 364 (13.5%) were exposed throughout pregnancy, and 238 (8.8%) were exposed only during the early stages of pregnancy. Participating children underwent magnetic resonance imaging assessment of the brain at a mean (SD) age of 10.1 (0.6) years. Exposure to smoking throughout pregnancy was associated with lower total brain volume, lower cerebral gray matter volume, lower cerebral white matter volume, smaller surface area, and less gyrification compared with no exposure.

The fetal brain is sensitive to the effects of smoking during pregnancy. 2 The neurotoxic effects of smoking are supported by withdrawal symptoms seen in newborns exposed to smoking. 2 In addition, smoking exposure has been linked with a significant range of neurobehavioral challenges during the first year of life. 3 Smoking exposure has been linked with smaller head circumference at birth, reflecting the size of the brain of the newborn. 2 The study by Zou et al 1 provides evidence that persistent exposure to maternal smoking during pregnancy might affect brain morphology 10 years later. It is noteworthy that 285 of the 364 exposed children (78.3%) had been exposed to fewer than 10 cigarettes per day. 1 Thus, only reducing the number of smoked cigarettes per day may not provide protection against the harmful effects of smoking during pregnancy.

A previous review by Bublitz and Stroud 4 showed that smoking exposure during pregnancy also has long-lasting adverse effects on brain function among adolescents assessed with functional magnetic resonance imaging. Those investigators found a lack of coordination across a large and diverse set of brain regions, including frontal, temporal, and parietal lobes and cerebellum during information and auditory processing among exposed children. The smoking exposure–related variations in brain development could translate to later maladjustment and mental health problems among adolescents. 4

Many of the mechanisms whereby smoking during pregnancy may affect brain development and later mental health are epigenetic in nature. 5 Smoking exposure is one of the most significant environmental factors associated with DNA methylation alterations. Thus, Zou et al 1 further studied whether previously identified smoking-associated DNA methylation patterns at birth mediated the observed associations. Variance in DNA methylation was indexed using a methylation risk score of 5643 5′-C-phosphate-G-3′ (CpG) sites rather than smoking-related CpG sites at an individual level. The neonatal DNA methylation risk score did not mediate the association between prenatal exposure to maternal smoking and brain morphology. Studies considering epigenetic pathways as a causal mechanism are only beginning to emerge, 5 and the study by Zou et al 1 is one of the first on smoking and brain development. Thus, more research is needed on this topic.

Zou et al 1 showed that children exposed to smoking only in the first trimester showed no differences in brain morphology compared with unexposed children. Thus, most of the harmful effects of smoking on brain development can be avoided if smoking cessation occurs as soon as possible during pregnancy. This finding is encouraging and emphasizes the importance of smoking cessation during pregnancy. It is important to exploit such information when encouraging pregnant women to quit smoking.

The biological mechanisms behind the potential effects of smoking exposure at the molecular level remain unclear. Nicotine is known to be responsible for many of the harms of smoking. 6 There is undisputed information on the harmful effects of nicotine in animal experiments, in which nicotine acts as a neuroteratogen. 7 Information on the effect of nicotine itself on fetal brain development is urgently needed because of the epidemic of new nicotine products, such as increasing use of electronic nicotine delivery systems. Convincing data on the fetal toxicity of nicotine are available 6 , 7 ; thus, there is no reason to wait for the results of epidemiological studies on the effects of nicotine itself. All efforts should be made to help pregnant women quit smoking as well as to stop the use of all other nicotine-containing products before pregnancy or as early as possible during pregnancy.

In summary, maternal smoking during pregnancy may exert long-lasting adverse effects on the brain development of offspring. The plausible role of nicotine must be considered owing to the increasing use of nontobacco products that contain nicotine. The goal should not only be smoke-free but also nicotine-free pregnancy, which would allow optimal brain development of offspring.

Published: August 1, 2022. doi:10.1001/jamanetworkopen.2022.24714

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2022 Ekblad MO. JAMA Network Open .

Corresponding Author: Mikael O. Ekblad, MD, PhD, Department of General Practice, Institute of Medicine, University of Turku, Turku 20014, Finland ( [email protected] ).

Conflict of Interest Disclosures: Dr Ekblad reported serving as the chairperson of the scientific broad of the Tobacco Free Finland 2030 organization. No other disclosures were reported.

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Ekblad MO. Association of Smoking During Pregnancy With Compromised Brain Development in Offspring. JAMA Netw Open. 2022;5(8):e2224714. doi:10.1001/jamanetworkopen.2022.24714

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Decline in smoking stalled after pandemic, study reveals

A long-term decline in smoking has stalled since the Covid-19 pandemic, with smokers increasingly turning to roll-ups, researchers have found.

A study by University College London (UCL), funded by Cancer Research UK, found overall cigarette consumption fell by 22 per cent – from 13.6 cigarettes a day to 10.6 – between 2008 and October 2019.

However, the data from 57,778 adult smokers who took part in the monthly survey between January 2008 and September 2023, showed the decline paused between late 2019 and 2023.

Researchers suggested this could be attributed to more people working from home following the pandemic, leading to them taking more regular smoking breaks.

The study, published in Nicotine & Tobacco Research, found the average smoker had 14 cigarettes a day in 2008, falling to 11 by 2019 – a figure which has not changed.

Roll-ups now most popular cigarettes

But self-rolled cigarettes have overtaken factory cigarettes in popularity, with an average of 5.7 consumed daily by smokers, against 5.4 manufactured cigarettes.

On average, smokers are getting through 35 per cent more hand-rolled cigarettes and 47 per cent fewer manufactured cigarettes since 2008.

Researchers suggested that this could be down to the price of manufactured cigarettes, which has been driven up by steep  tax rises.

Dr Sarah Jackson, lead author of the paper and principal research fellow at UCL’s Institute of Epidemiology and Health Care, said:  “This 15-year study captures shifts in smoking behaviour, showing that while the average number of cigarettes smoked per day has fallen, this trend has stalled since 2019.

“People are increasingly opting to use cheaper hand-rolled tobacco over more expensive manufactured cigarettes, proving that consistency in taxation and regulation across all cigarette types is key.

“Some groups across England still smoke more heavily than others. It’s vital that smoking cessation services are made easily and equally available across the UK, so that those who want to quit smoking are given all the support they need to do so.”

Cancer Research UK called for Rishi Sunak’s legislation aiming to create a “smoke-free generation” to pass through Parliament “swiftly” in a bid to reduce cancer rates caused by smoking .

Government ‘must not let up’

The charity said smoking causes about 15 different types of cancer, and leads to the equivalent of about 150 cases of the disease every day.

In October,  Mr Sunak unveiled plans to introduce legislation that would make it illegal to sell tobacco products to anyone born after Jan 1 2009.

Dr Ian Walker, the executive director of policy at Cancer Research UK, said the UCL study “makes it clear that the UK Government must not let up in its fight to reduce smoking”.

“All tobacco products are harmful, and more work needs to be done to end cancers caused by smoking for good,” he added.

Mr Sunak’s Tobacco and Vapes Bill will raise the legal age for buying tobacco – currently 18 – every year by one year so that people born in or after 2009 will never legally be able to buy cigarettes.

The Bill cleared its first Commons hurdle last month, with MPs voting 383 to 67 to give it a second reading.

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Bumble founder and executive chair Whitney Wolfe Herd raised eyebrows this week with her comments about how AI might change the dating experience. During an onstage interview, Bloomberg’s Emily Chang brought up bots posing as real people, or real people falling in love with bots, as examples of how AI might make online dating worse.

Alora Baby aims to push baby gear away from the 'landfill economy'

Enter Alora Baby, which is trying to shift the narrative toward a greener and more sustainable option for manufacturing — and recycling — baby products. Alora Baby, backed by government grants, aims to introduce revolutionary changes to baby equipment, moving away from the norm that sees products designed for a single lifespan. “We are stuck in this system, which I call the landfill economy, which is basically where stuff just gets crappier: Materials are more expensive, labor is less and less exploitative (thankfully!), but we don’t have the fuel for this machine anymore,” said Angus Whiston, Alora Baby's founder, in an interview with TechCrunch.

SNL Recap: Maya Rudolph vogues her way back into 30 Rock in a Mother's Day-themed episode

The 'SNL' alum revived her Beyoncé impression, with a new Cowboy Carter twist.

Inflation and consumer spending updates ahead: What to know this week

A crucial reading of inflation faces investors in the week ahead after a string of disappointing reports to start the year dampened investors' interest rate cut hopes.

The T-shirt folding board shoppers say makes 'doing the laundry fun' is just $11 at Amazon

This problem-solving gadget takes the hassle out of getting your drawers and closets organized.

Fed officials stick to Powell’s higher-for-longer script as a key inflation reading looms

Jay Powell’s colleagues spent the last week backing a stance the central bank chair hammered home at his last press conference: Interest rates will be staying higher for longer.

CD rates today, May 12, 2024 (up to 5.15% APY)

If you’re searching for today’s best CD rates, we’ve narrowed down some of the top offers. Learn more about CD rates today.

Whip it good: 25,000+ shoppers use this $6 milk frother for foamy drinks at home — get it for 65% off

Starbucks who? 'Tastes like I’m drinking a cappuccino from a fancy coffee shop,' says one fan.

The best oil drain pans of 2024

For those inclined to save some money and work on their own cars, getting an oil drain pan is one of the first steps in changing your vehicle's oil.

Pirates' Paul Skenes strikes out 7 Cubs over 4 innings in MLB debut

Skenes was lifted in the top of the fifth inning after 84 pitches.

U.K. agency releases tools to test AI model safety

The U.K. Safety Institute, the U.K.'s recently established AI safety body, has released a toolset designed to "strengthen AI safety" by making it easier for industry, research organizations and academia to develop AI evaluations. Called Inspect, the toolset -- which is available under an open source license, specifically an MIT License -- aims to assess certain capabilities of AI models, including models' core knowledge and ability to reason, and generate a score based on the results. In a press release announcing the news on Friday, the Safety Institute claimed that Inspect marks "the first time that an AI safety testing platform which has been spearheaded by a state-backed body has been released for wider use."

Q&A with Maddy Dychtwald: What the longevity revolution means for women

Women are living longer than men, but they often spend the last decade or so in "a cascade of poor health,” author Maddy Dychtwald said.

Why Apple’s ‘Crush’ ad is so misguided

This week Apple unveiled new iPad models at its Let Loose event, including a new 13-inch display for the iPad Air, as well as Tandem OLED and a new M4 chip for the iPad Pro. For Apple completionists, we compiled all of the new announcements in case you missed it. In the world of EVs, the embattled Fisker Ocean is facing yet another federal safety probe.

Women in AI: Rachel Coldicutt researches how technology impacts society

To give AI-focused women academics and others their well-deserved — and overdue — time in the spotlight, TechCrunch has been publishing a series of interviews focused on remarkable women who’ve contributed to the AI revolution. In the spotlight today: Rachel Coldicutt is the founder of Careful Industries, which researches the social impact technology has on society. Clients have included Salesforce and the Royal Academy of Engineering.

28 Years Later is coming to theaters next summer

Fans have been waiting a long, long time for another installment in the 28 Days Later franchise, and we now know when the next followup is coming out: June 20, 2025. 28 Years Later will be directed by Danny Boyle and written by Alex Garland.

SAP’s chief sustainability officer isn’t interested in getting your company to do the right thing

SAP chief sustainability officer Sophia Mendelsohn has been on the job since September, but her career really goes back to her undergraduate years at Harvard when she studied sustainability. Ever since her first job working in China, she observed the connection between prosperity and sustainability. “I've been in sustainability a minute, before it was cool,” Mendelsohn told TechCrunch.

Lions' Terrion Arnold said he'd jam his mother into the dirt if they lined up against each other

Detroit Lions rookie cornerback Terrion Arnold gave a memorable quote about his mother and how important she has been in his development as a player.

What we’re listening to: Trail of Flowers, Hyperdrama, Science Fiction and more

In this installment of What We're Listening To, the Engadget team discusses some of the recent releases we've had on repeat, including new music from Sierra Ferrell, Justice, Utada Hikaru and Caroline Polachek.

The 40+ best Amazon deals this weekend: Save up to 80% on vacuums, gardening tools, tech goodies and more

We've got our eye on a viral Bissell carpet cleaner on rare sale for $99, plus an Apple iPad marked down by $80, to name a few.

Bill Belichick will appear on every ESPN 'ManningCast' this season, says Peyton Manning

Bill Belichick will appear on every episode of ESPN's "ManningCast" this season, according to Peyton Manning, The legendary coach is expected to join the show during the first quarter.