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

Background/Aims: E-cigarettes are frequently used by people who smoke. This study examined 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. Results: Across the period, the overall prevalence of dual use increased non-linearly from 3.5% to 5.3% 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 18-24-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: The proportion of smokers in England who vape has increased rapidly 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.