Prescribed Medication Burden by Tobacco Smoking and E-Cigarette Use Status

Tobacco smoking is a major driver of chronic disease, and e-cigarette use is increasingly common, yet their associations with prescribed medication burden remain unclear.

We analysed data from 1657 adults aged ≥ 16 years who completed a nurse visit in the Health Survey for England 2021. Smoking and e-cigarette status were categorized into four mutually exclusive groups: never users, current smokers, current exclusive e-cigarette users, and ex-smokers. Prescribed medication use in the past 7 days was verified by nurses and grouped into seven BNF-based therapeutic categories: cardiovascular, metabolic, respiratory, pain and anti-inflammatory, gastrointestinal, mental health, and anti-infectives. Overall, medication burden was categorized as none, one, two, or three or more prescribed medicines. Generalized ordered logistic regression estimated associations with overall burden, and Firth penalized logistic regression examined therapeutic categories, adjusting for age, sex, education, and area-level deprivation. Sensitivity analyses restricted the sample to adults aged ≥ 45 years.

Ex-smokers reported the highest medication burden, with 20.3% prescribed three or more medicines compared with 8.6% of never users, 10.9% of current smokers, and 12.2% of current e-cigarette users (p < 0.001). In adjusted analyses using never users as the reference group, ex-smokers had significantly greater odds of higher overall burden (OR = 1.50, 95% CI: 1.21-1.87, p < 0.001). Current smokers (OR = 0.86, 95% CI: 0.60-1.24, p = 0.42) and e-cigarette users (OR = 1.63, 95% CI: 0.93-2.83, p = 0.09) did not differ significantly from never users. By therapeutic category, current e-cigarette users, compared with never users, had higher odds of pain and anti-inflammatory medication use (OR = 3.61, 95% CI: 1.70-7.67, p = 0.001). Ex-smokers, relative to never users, also had elevated odds of respiratory (OR = 1.72, 95% CI: 1.17-2.55, p = 0.006), gastrointestinal (OR = 1.56, 95% CI: 1.17-2.07, p = 0.002), and anti-infective prescriptions (OR = 3.32, 95% CI: 1.63-6.79, p = 0.001). Sensitivity analyses restricting to those aged ≥ 45 years produced consistent results.

Ex-smokers had the highest medication burden compared with never users, which may partly reflect reverse causation, whereby illness and associated treatment prompt smoking cessation, though residual effects of prior smoking cannot be excluded. Current smokers showed no significant excess burden, possibly due to a "healthy smoker" effect, and e-cigarette use was not associated with overall burden compared with never users, although it was linked to greater use of pain and anti-inflammatory medicines.