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National no smoking day, held this year on the 13 March, is a day dedicated to spreading awareness of the destructive impacts of smoking, inspiring individuals to give up smoking and promoting healthy ways of life and a smoke-free environment. To mark the day, Nuffield Department of Primary Care Health Sciences researchers Dr Jonathan Livingstone-Banks and Dr Nicola Lindson, discuss ongoing research into the impact of e-cigarette flavours and the international policy implications of the findings.

Tobacco use is still one of the UK’s leading causes of death and illness, and evidence-based tobacco control policy is as important as ever. The UK has a reputation as a leader in tobacco control policy based on rigorous and high-quality evidence, which we in the Nuffield Department of Primary Care Health Sciences are proud to contribute to. But none of this happens in a vacuum – tobacco use is a world-wide problem and if we’re to provide the best evidence to inform UK policy, we need to look beyond our borders. Across the world we find striking differences and similarities in concerns about tobacco and nicotine products and what control policies are in place. This makes it important to collaborate internationally to identify and address common high priority problems to maintain UK’s place as a world-leader in tobacco control policy. Such collaboration gives a broader world-view to the work that informs UK policy and reduces research waste by combining researcher efforts

To this end, in October 2023 CEBM researchers Dr Nicola Lindson and Dr Jonathan Livingstone-Banks, who work in the OxTAG research group, won funding from the NIH along with former NDPCHS researcher Jamie Hartmann-Boyce to join the Center for the Assessment of Tobacco Regulations (CAsToR) in the USA, to conduct high-impact and timely research on tobacco and nicotine control regulations, reporting directly to the U.S. Food and Drug Administration (FDA). Our work with CAsToR involves conducting evidence syntheses that can provide reliable and timely insights on the behavioural and public health impacts of FDA tobacco rules or other regulatory actions.

Our first topic focusses on e-cigarette flavours – currently a hot topic in the UK and across many parts of the world – investigating their impact on smoking cessation, health impacts and long-term use of EC, and impact on appeal and uptake of EC use. We are conducting two pieces of work: an update of a secondary analysis of our Cochrane living review of e-cigarettes for smoking cessation looking at the impacts of flavours on quitting smoking and long-term e-cigarette use, and an overview of reviews investigating their impacts more broadly.

The issues surrounding e-cigarette flavours are not black and white. Flavours are generally considered to make e-cigarettes more appealing. This is a concern in instances such as young people who have never smoked being attracted to the flavours and starting to vape. On the other hand, the appeal of flavours may also play an important role in how effective e-cigarettes are in helping smokers to quit. The important challenge for government policy is to find the right balance to capitalise on the benefits of e-cigarettes for helping people to quit smoking while minimising the risks of people who don’t smoke starting vaping. If the research found that flavours weren’t an important factor for people quitting smoking with e-cigarettes, then the policy implications would be simple; banning flavours would be the way to go. However, if they are important then banning them outright could risk throwing the baby out with the bathwater.

Our work so far has found that flavours may be an important to adults looking to quit smoking, as many switch between flavours during the quitting process. However, the research is still limited and we will need more evidence before we can draw clear conclusions. We will be feeding this, along with other results, directly back to the FDA and, taking advantage of our international networks, we are well placed to disseminate our results both here (through partners in the Office for Health Improvement and Disparities and Action on Smoking and Health) and in the US.

This is only the beginning on our work on this five-year grant, but we’re excited to work on more critical topics in response to policy-maker priorities going forward.

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