Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

Abstract

BackgroundWhile some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.MethodsTen electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.ResultsWe identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.ConclusionsThe only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that – even where NCNP use is higher among low SES groups – this does not necessarily replace smoked tobacco use in these groups.

Associations of Socioeconomic Status, Parental Smoking and Parental E-Cigarette Use with 10–11-Year-Old Children’s Perceptions of Tobacco Cigarettes and E-Cigarettes: Cross Sectional Analysis of the CHETS Wales 3 Survey

“…We found substantial overlap between parental smoking and vaping; children with a parent figure who vaped had greater odds of having a parent who smoked, and vice versa. While some previous research finds greater use of e-cigarettes among more advantaged socioeconomic groups [50], or limited evidence of use by groups in which smoking is commonly concentrated [51], reports of parental e-cigarette use were higher among children from more deprived families in our sample, although these socioeconomic differences were attenuated to non-significance on adjustment for the higher rates of parental smoking in poorer families. Where parental smoking was not adjusted for, having a parent figure who vaped was associated with almost all measured outcomes, including greater exposure to tobacco cigarettes and e-cigarettes in shops, increased susceptibility to vaping and smoking, and a greater likelihood of perceiving both vaping and smoking as normal.…”

Impact of population tobacco control interventions on socioeconomic inequalities in smoking: a systematic review and appraisal of future research directions

“…Population interventions involving e-cigarettes were not considered as they were covered by a recent review of the equity impact of non-combustible nicotine products. 18 …”

Future smoking prevalence by socioeconomic status in England: a computational modelling study

“…31 However, possible impacts of the use of electronic cigarettes on social inequalities in smoking remain uncertain. 32 The population of smokers in England is shrinking over time, following continued declining in smoking prevalence. To achieve the TFA target by 2030, the average number of quitters required each year during 2017-2030 needs to be increased by 8% in the HEQlow group, compared with that in 2016.…”