Trends in Exclusive Non-Cigarette Tobacco Smoking in England: A Population Survey 2013-2023

Abstract

Introduction: The UK Government intends to implement a "smokefree generation" policy prohibiting the sale of all tobacco products to people born after 2008. National surveys provide comprehensive data on cigarette smoking, but little is known about patterns of non-cigarette tobacco smoking across key population groups.

Aims and methods: Using data from a nationally representative cross-sectional survey of adults in England, collected monthly between September 2013 and September 2023 (n = 196 721), we estimated time trends in exclusive non-cigarette tobacco (eg, cigar/pipe/shisha) smoking prevalence, overall and by age, gender, occupational social grade, region, ethnicity, and vaping status. Interviews were conducted face-to-face until March 2020 and via telephone thereafter.

Results: From September 2013 to September 2023, there was a non-linear increase in exclusive non-cigarette tobacco smoking prevalence (from 0.36% to 1.68%; prevalence ratio = 4.72 [95% CI = 3.43-6.48]). Prevalence was relatively stable up to February 2020 (at an average of 0.46%), then increased sharply at the start of the COVID-19 pandemic (at the same time as survey methods changed), to 0.90% (0.82%-0.99%) in March 2020. This was followed by a steadier rise, peaking at 1.97% in May 2022, before falling slightly to 1.68% by September 2023. In 2022/2023, 1 in 10 smokers (10.8% [9.64%-12.0%]) exclusively used non-cigarette tobacco. The rise in prevalence was observed across all subgroups but was most pronounced among younger adults (eg, reaching 3.21% of 18-year-olds vs. 1.09% of 65-year-olds). Prevalence was consistently higher among men and current vapers.

Conclusions: Although exclusive use of non-cigarette combustible tobacco remains rare among adults in England, it has increased in recent years, particularly among younger ages. As of September 2023, there were approximately 772 800 adult exclusive non-cigarette tobacco smokers in England; around five times more than a decade earlier.

Implications: The proportion of adults in England who do not use cigarettes at all but smoke other combustible tobacco products has increased substantially in recent years, with a particularly pronounced rise among young people. The inclusion of non-cigarette combustible tobacco products under the proposed "smokefree generation" policy is therefore likely to be important for achieving the greatest reduction in youth uptake of tobacco smoking, as it would ensure young people who are unable to legally buy cigarettes do not buy other combustible tobacco products that are similarly harmful to health.

Figure 1.

Trends in exclusive non-cigarette tobacco smoking among adults in England, September 2013 to September 2023. Panel A shows the results of the primary model, which modeled survey wave non-linearly using restricted cubic splines (five knots). Panel B shows the results of an unplanned sensitivity analysis, which used a segmented regression approach to model associations of the start of the COVID-19 pandemic with a step-level change in prevalence and a change in trend. Lines represent modeled weighted prevalence by monthly survey wave. Shaded bands represent 95% confidence intervals. Points represent unmodeled weighted prevalence by month.

Figure 2.

Trends in exclusive non-cigarette tobacco smoking within subgroups of adults in England, September 2013 to September 2023. Panels show trends by (A) age, (B) gender, (C) occupational social grade, (D) region in England, (E) ethnicity, and (F) vaping status. Lines represent modeled weighted prevalence by monthly survey wave, modeled non-linearly using restricted cubic splines (five knots). Shaded bands represent 95% confidence intervals.