Trends in long term vaping among adults in England, 2013-23: population based study

Comparison with other studies

The timing of the sharp rise in long term vaping coincided with the rising popularity of new disposable e-cigarettes from Spring 2021.78 This suggests that the recent increase in vaping among adults—particularly young adults—in England does not just reflect an increase in experimental use, but rather that a substantial number of those taking up vaping are going on to vape long term. Our data also suggest that most of those vaping long term are vaping daily, including more than two thirds of those who have never regularly smoked (ie, it is not just infrequent use over a long period). In addition, although in recent years small increases in long term vaping using refillable and pod devices have occurred, the increase in long term vaping using disposable devices was substantially larger. This indicates that many vapers are now continuing to use disposable devices over the long term, rather than transitioning to rechargeable devices.

We observed notable differences in trends in long term vaping by age and smoking status. The recent and rapid rise in long term vaping followed a clear inverse age gradient that mirrored the pattern we have seen for the prevalence of current vaping using disposable devices over this period.78 The rise occurred predominantly among current and former smokers, but an increase in long term vaping also occurred among those who had never regularly smoked. This is not necessarily a cause for concern if vaping is diverting people who would have otherwise smoked towards a less harmful nicotine product. Simulation modelling of trends in smoking and vaping among adolescents in the US suggests a substantial diversion effect is likely.26 However, if these people would not have otherwise taken up smoking, then taking up vaping as a regular habit will expose them to greater harm than if they had neither vaped nor smoked.3 With a growing proportion of people using e-cigarettes, it becomes increasingly unlikely that all would have used cigarettes instead, given the declining trends in prevalence of cigarette smoking.27 Across our study period, national estimates of smoking prevalence among adults in England fell from 18.8% in 2013 to 12.9% in 2022.27 Recent data indicate a rise in the proportion of young adults using inhaled nicotine (ie, vaping or smoking) since disposable e-cigarettes became popular in the absence of an acceleration in the decline in smoking, although declines in smoking appear to have been most pronounced in age groups with the largest increase in vaping.2728 Our current study shows that the proportion of young adults vaping long term is now higher than smoking rates have been in this age group since 2017.27 A similar pattern has been documented among adolescents, with rates of current vaping among 11-17 year olds in Great Britain in 2023 higher than smoking rates in this age group have been for more than a decade.5

Our definition of long term vaping was use of e-cigarettes for a period of more than six months and was an operational definition to indicate possible dependent use. It is not necessarily indicative of a length of time at which we would expect substantial harms from vaping to have already accumulated. In discussions about the risks associated with e-cigarettes, a key concern is that the harms of long term use are not yet fully understood—in this context, long term use refers to decades rather than the much shorter duration of use focused on in our analysis. Even most of the well established harmful effects of tobacco smoking on health outcomes only become apparent after years and decades, rather than months, of use. Existing evidence suggests the long term health risks of vaping are likely to be substantially lower than the risks of smoking.3

Policy implications

Our findings raise two key issues with implications for policy. Firstly, disposable e-cigarettes appear to be attracting young adults to establish long term e-cigarette use. Long term vaping among young adults has increased exceptionally since 2021, and as of October 2023 it did not yet show signs of stopping. This adds weight to calls for tighter regulation of vaping products to reduce their appeal to young people29 and highlights the urgency of this action. Disposable e-cigarettes might appeal to young people for a variety of reasons, including affordability, sleek design and branding, attractive in-store displays, and ease of access.293031 Any policies intended to reduce young people’s interest in vaping, however, must be carefully considered in case they discourage people from using e-cigarettes as a smoking cessation aid.3233 Simultaneously meeting both goals will likely present challenges. The UK government is considering restricting e-cigarette flavours, restricting branding across all e-cigarette products and packaging, and restricting the visibility and promotion of e-cigarettes in shops.34 Although sweet and fruit flavours likely increase the appeal of e-cigarettes to young people,35 they are also important to adult smokers,3637 so restricting them may discourage smokers from switching to vaping. Consistent with this, recent data from the US suggest that restrictions on the sale of flavoured e-cigarettes are associated with increased cigarette sales.38 Similarly, restricting the visibility and promotion of e-cigarettes in shops, while helping to discourage use by adolescents and young adults, might also lead to some degree of reduction in smokers’ use of e-cigarettes in quit attempts. This could potentially be mitigated by public health campaigns promoting the use of e-cigarettes as a cessation aid, including at the point of sale. Explicitly targeting e-cigarette advertising towards older smokers—who are less likely to be using e-cigarettes and could benefit most from using them to stop smoking—could also be helpful in positioning these products as something that older people use and making them less attractive to adolescents and young adults without a smoking history. An additional measure the government is reported to be considering is to apply a tax to e-cigarettes to increase the price and make them less affordable to young people.39 When raising the price of e-cigarettes, it would be important to make sure that they remain less expensive than cigarettes,4041 to mitigate unintended reductions in their use for smoking cessation. US data suggest that higher tax rates on e-cigarette products are associated with reductions in use of e-cigarettes but increases in cigarette smoking among young adults.42

The second issue is that as of October 2023, half of long term vapers are mainly or exclusively using disposable devices (and most are using them every day), which has a substantial impact on the environment. A typical disposable e-cigarette is designed for single use and contains plastic, rubber, and copper, and a lithium battery. Although some parts (eg, the battery) can be widely recycled, other parts (eg, rubber) cannot, and devices are not generally designed to be taken apart easily. If they are not disposed of correctly, they can potentially release plastic, electronic, and hazardous chemical waste into the environment.14 There have been calls for an outright ban on disposable e-cigarettes,434445 and the UK government recently announced its intention to follow this course of action.34 However, these products offer advantages for certain groups (eg, those with severe mental illness, who may find them easier to use4647) and in certain situations (eg, for short term use when a person has forgotten their rechargeable e-cigarette or the battery has run out while out). Raising the upfront cost of disposable e-cigarettes to more than that of the cheapest reusable e-cigarettes (eg, through an excise tax), thus making reusable e-cigarettes a more cost-effective alternative, may encourage long term vapers to transition to less environmentally damaging products over time,29 while allowing disposable devices to remain available to those who need them more.

Directions for future research

Our findings also raise questions that could be addressed in future research. Firstly, have similar increases occurred in long term vaping among adolescents, or in other countries where disposable e-cigarettes have become the dominant product used? The 2023 Action on Smoking and Health (ASH) Smokefree GB Youth Survey found that while 20.5% of 11-17 year olds surveyed had tried vaping, most of this was experimentation (11.6% tried once or twice) or occasional use (3.9% use less than once a week).5 However, recent data from the International Tobacco Control Youth Tobacco and Vaping Survey suggest that increases in vaping prevalence among young people (aged 16-19 years) in England, the US, and Canada over recent years have been accompanied by greater levels of dependence on vaping (including increases in perceived addiction, urges, and frequency of use),48 which could lead to an increase in long term use.

Secondly, to what extent has the covid-19 pandemic contributed to the rising prevalence of vaping among young people? Although our data clearly show a sharp rise in long term vaping among adults since disposable e-cigarettes became popular (including in the segmented regression model, which adjusted for the onset of the pandemic), visual inspection of unmodelled data points also suggests a modest increase around the start of the pandemic (fig 1). Although some of this is likely to be attributable to an increase in smoking cessation during the acute phase of the pandemic,4950 other factors may have contributed to the rise—particularly among young people (eg, stresses associated with reduced social contact, and disruption to school and university study and exam schedules).

Finally, what are the motives for long term vaping among current smokers? Our data suggest that more than one in three recent former smokers and one in six long term former smokers is a long term vaper. It is likely that a sizable proportion of each group quit smoking by vaping, since e-cigarettes are the most popular cessation aid in England (used in around a third of quit attempts),4 are effective for helping people quit,12 and have been associated with reductions in smoking prevalence at population level.515253 It would be interesting to know more about why the 23% of current smokers who are long term vapers use e-cigarettes—for example, are they trying to quit smoking or reduce their cigarette consumption for harm reduction, or are they using e-cigarettes situationally,54 possibly sustaining their smoking—and to what extent do these motives differ by socioeconomic position or other sociodemographic or smoking related factors?

Strengths and limitations of this study

Strengths of this study include the large, representative sample and repeated monthly assessments over a 10 year period. Limitations relate to the study design and measures. Although we have speculated that the rise in popularity of disposable e-cigarettes may have contributed to the substantial increase in long term vaping we observed, the correlational design means we cannot definitively infer causality. We used a hybrid sampling approach rather than random probability sampling, although comparisons with other sources—national probability surveys and sales figures—suggest that the survey recruits a nationally representative sample and produces similar estimates of key smoking related variables.1718 Our sample focused on adults, so the data do not offer any insights into the extent to which the recent rise in vaping among adolescents reflects long term use versus experimental use.

The assessment of vaping in the Smoking Toolkit Study is somewhat unusual (described in the methods section) because it was not initially a priority when first added in 2011, and subsequently the team have not wanted to lose long term comparability of the trends. However, we see close alignment in estimates of vaping prevalence with other nationally representative surveys in England that use more straightforward language. The items assessing vaping identified participants who reported using an e-cigarette for any reason. Although we did not restrict the definition of long term vaping to vaping using nicotine, because nicotine content was not assessed in every wave and not everyone knows the nicotine content of the device they use, most (87% of those asked) said their usual device contains nicotine.

The main device type used by vapers was not assessed before July 2016, so we were unable to model trends in long term vaping by device type across the entire period. In addition, no definition was provided for “mainly used” when asked about device type, so it was open to participants’ interpretation. The items assessing vaping frequency and main device type only captured current behaviour, so our data do not offer insight into how these variables had changed within individuals with increasing duration of vaping. While this may have biased absolute estimates of prevalence, it should not affect time trends observed across individuals.

The item assessing vaping duration asked how long people who reported using e-cigarettes (or other nicotine products) had been using “this nicotine replacement product or these products,” which may have led to underreporting among participants who did not consider e-cigarettes to be a form of nicotine replacement (eg, never smokers). The Smoking Toolkit Study has, however, produced similar estimates of current vaping prevalence to other national surveys.

The measures of duration and frequency of use were not specific to vaping but covered all non-combustible nicotine products participants reported using, but most long term vapers in the sample reported only using e-cigarettes, and the results of a sensitivity analysis restricting the definition of long term vaping to those who did not also use other products showed a similar pattern.

Finally, our approach to determining smoking status meant that the never smoker group could include some people who smoked for less than a year (although it is likely that many people who previously smoked would select a response option that classified them as a former smoker, given that the question asked which descriptor applied to them best). However, before 2020, this measure indicated a low prevalence of long term vaping among never smokers and much higher prevalence among current and former smokers. Given the considerable change in trends we observed, it seems unlikely that this limitation could explain the pronounced increase in long term vaping. Moreover, even if everyone who reported long term vaping had a history of smoking (whether it was disclosed in response to the item assessing smoking status), this would represent a serious departure from recent trends in smoking that warrants attention.

Conclusions

The prevalence of long term (>6 months) vaping increased substantially among adults in England from 2013 to 2023. Much of this increase occurred from 2021, coinciding with the rapid rise in popularity of disposable e-cigarettes. Half of long term vapers now mainly or exclusively use disposable devices. The growth has been concentrated among people with a history of regular smoking, but an increase has also occurred among those who have never regularly smoked, especially young adults.