E-cigarette use and smoking-related disparities in England: an observational study using small area estimation and...

The uptake of e-cigarettes has been associated with reduced smoking in the UK, and British public health policy has sought to leverage e-cigarettes' potential to encourage cessation. Smoking harms are concentrated in disadvantaged communities in the UK. If e-cigarette use were similarly concentrated in these groups, that could help redress the inequity. On the other hand, disadvantaged communities may be slower to adopt e-cigarettes, and this could perpetuate or exacerbate smoking-related disparities.

This study examines the association between community-level e-cigarette prevalence and disparities in smoking between those employed in routine and manual occupations (R&M) and those employed in professional, managerial, intermediate, and other (PMI) occupations in England between 2013 and 2019. Using observational data, a small area estimation model is employed to form synthetic estimates of e-cigarette prevalence at the local level. The local socioeconomic gap in smoking (or smoking prevalence by occupation group) is then nonparametrically regressed on the estimated local e-cigarette prevalence.

The uptake of e-cigarettes is negatively associated with smoking rates in both occupational groups, affirming the role of e-cigarettes as an opportunity for harm reduction. However, the decrease in smoking is smaller for R&M workers. Thus, the uptake of e-cigarettes may have slightly increased the disparity between the two groups.

Small area estimation provides a useful way to synthesize local estimates of e-cigarette use when direct estimation is impossible. The analysis suggests that the uptake of e-cigarettes, while associated with cessation from smoking for both types of workers, may not immediately reduce smoking-related disparities. Additional investigation should examine why the uptake of e-cigarettes may have a less marked effect on smoking cessation among R&M workers and whether these results change as the e-cigarette market matures. The analysis highlights the need to ensure that cessation interventions delivering net benefits reach the communities whose need is greatest.