Trends and patterns of dual use of combustible tobacco and e-cigarettes among adults in England: A population study, 2016-2024

Abstract

Background/aims: E-cigarettes are frequently used by people who smoke. This study measured how the prevalence and patterns of smoking and vaping ('dual use') in England have changed as the vaping market has rapidly evolved.

Design: Representative monthly cross-sectional survey, July 2016 to April 2024.

Setting: England.

Participants: 128 588 adults (≥18y).

Measurements: Logistic regression estimated associations between survey wave and dual use. Descriptive statistics were used to analyse patterns of smoking and vaping, overall and by sociodemographic, smoking and vaping characteristics and harm perceptions of e-cigarettes vs. cigarettes.

Findings: Across the period, the overall prevalence of dual use increased non-linearly from 3.5% to 5.2% of adults [prevalence ratio (PR) = 1.49 (1.25-1.76)]. Among adults who smoked, the proportion who also vaped was relatively stable up to mid-2021, at an average of 18.6% between July 2016 and May 2021, then increased rapidly to 34.2% by April 2024 [PR = 1.76 (1.48-2.09)]. This increase was greatest at younger ages [e.g. from 19.6% to 59.4% among 18- to 24-year-olds; PR = 3.04 (2.28-4.23)]. The most common pattern of dual use across the period was daily cigarette smoking with daily vaping [49.0% (47.3-50.8%)]. Over time, the proportion of dual users reporting daily cigarette smoking with non-daily vaping decreased [from 35.2% to 15.0%; PR = 0.43 (0.29-0.63)], offset primarily by an increase in the proportion reporting non-daily cigarette smoking with daily vaping [from 7.6% to 21.5%; PR = 2.84 (1.71-4.72)]. Daily cigarette smoking with daily vaping was more common (and non-daily cigarette smoking with daily vaping less common) among dual users who were older, less advantaged, mainly smoked hand-rolled cigarettes, had stronger urges to smoke and had been vaping for ≤6 months. Daily vaping was more common among dual users who thought e-cigarettes were less/equally harmful as cigarettes, or were unsure.

Conclusions: In England, vaping prevalence has increased rapidly among adults who smoke since 2021, which was when disposable e-cigarettes started to become popular. Since 2016, patterns of dual use have shifted away from more frequent smoking towards more frequent vaping. This may be the result of increasing prevalence of dual use among younger adults, who are more likely than older dual users to smoke non-daily and vape daily.

Keywords: dual use; e‐cigarettes; population study; smoking; trends; vaping.

FIGURE 1

Trends in the overall prevalence of dual use of smoking and vaping in England, July 2016 to April 2024. Lines represent the modelled weighted proportion by monthly survey wave (modelled non‐linearly using restricted cubic splines with five knots). Shaded bands represent 95% CIs. Points represent the unmodelled weighted proportion by month. Sample sizes and modelled estimates of prevalence in the first and last months in the time series are reported in Table 1. Corresponding figures with age analysed as a continuous variable are provided in Figure S2.

FIGURE 2

Trends in different patterns of dual use of smoking and vaping in England, 2016 to 2024. (a) Shows the proportion of adults who reported each pattern of dual use, aggregated by survey year (July–June). *Sample excludes dual users who reported that they did not know how frequently they vaped; Figure S4 shows data including these participants. **2023/2024 only includes data up to April. Corresponding figures for adults who smoked and dual users are provided in Figure S5. (b) Shows modelled time trends in the proportion of dual users who reported each pattern of dual use. Lines represent the modelled weighted proportion by monthly survey wave (modelled non‐linearly using restricted cubic splines with five knots). Shaded bands represent 95% CIs. Points represent the unmodelled weighted proportion by month. Modelled estimates of prevalence in the first and last months in the time series are reported in Table 4.