Sharon Cox

Smoking prevalence falling below 10% is a milestone to celebrate, not evidence that the job is almost done. A smokefree future requires sustained prevention and cessation efforts, alongside surveillance that better captures who smokes, what they use, and who is being missed.

Aims: To examine oral nicotine pouch use among United States (U.S.) middle and high school students by (1) estimating prevalence in 2025 across demographic and other tobacco/nicotine product use subgroups, (2) assessing trends from 2021 to 2025, and (3) identifying factors independently associated with current pouch use. Design: Annual cross‐sectional survey. Setting: United States. Participants: 124 264 middle and high school students (typically aged 11–18 years) in the National Youth Tobacco Survey 2021–2025 (n = 20 413, 28 291, 22 069, 29 861 and 23 630). 117 864 students with classifiable pouch use were included in the trend analyses and 22 854 in the 2025 analyses. Measurements: We estimated annual survey‐weighted prevalence of ever, current (≥1 day in the past 30 days) and current frequent (≥20 days) pouch use, overall and by sex, school level, race/ethnicity, and by current use of cigarettes, e‐cigarettes, other non‐pouch products and any non‐pouch product, each analysed separately. Trends were assessed with survey‐weighted Poisson regression using orthogonal linear and quadratic year contrasts, the quadratic testing departure from a constant multiplicative trend. Using 2025 data we estimated adjusted prevalence ratios (APRs) for current pouch use. Results: In 2025, 3.8% [95% confidence interval (CI): 3.1–4.6] of students reported ever using pouches, 1.7% (1.4–2.1) current use, and 0.4% (0.3–0.6) frequent use. Current use rose from 0.8% (0.6–1.0) in 2021 to 1.6% (1.1–2.2) in 2023 then changed little at 1.8% (1.5–2.1) in 2024 and 1.7% in 2025. The quadratic year term was 0.75 (0.57–0.99), consistent with deceleration but imprecise. Ever use rose across all five waves from 2.1% (1.7–2.5) with no departure from linearity (quadratic 1.00, 0.81–1.22). Increases were consistent across subgroup levels with reliable estimates in all years. In 2025, current pouch use was higher among males (2.4% vs. 1.0%) and among current users of any other product (20.6% vs. 0.4%). Most current pouch users (77.4%) also currently used another product, though 11.1% reported no lifetime use. In fully adjusted models, associations were strongest for other non‐pouch product use (APR = 13.78, 95% CI: 8.39–22.65), then e‐cigarette (4.32, 2.75–6.80) and cigarette use (1.49, 1.08–2.07). Summary: Oral nicotine pouch use among United States middle and high school students remains uncommon. Current use rose between 2021 (0.8%) and 2023 (1.6%) and has since levelled off, while ever use continued to increase. Use is largely concentrated among users of other tobacco or nicotine products, but a minority report no current or lifetime use of other products.

Behavioural research is a multidisciplinary field essential for addressing societal challenges, but it suffers from inconsistent terminology that impedes knowledge synthesis and communication across disciplines. This study used consensus methods to develop informal and ontological definitions for seven key behavioural research terms: individual behaviour, population behaviour, individual behaviour change, behavioural theory, behavioural research, behavioural science, and leadership. Using a seven-step iterative method involving a literature review, expert consultations, and feedback from diverse behavioural researchers and users, the team refined definitions to enhance clarity, inclusivity, and cross-disciplinary understanding. The resulting definitions were accompanied by elaborations and examples to provide context and concrete illustrations of the terms. These shared definitions provide a standardised vocabulary to improve study and intervention design and reporting, evidence synthesis, and translation of evidence into policy and practice. While acknowledging limitations such as sample bias, this work lays a foundation for clearer communication and future advances in behavioural research.

Introduction: England provides comprehensive support for cigarette smoking cessation, and some services also assist people who use non-cigarette tobacco products (eg, cigars/cigarillos, shisha, and chewing tobacco). Little is known about whether users are interested in quitting, their willingness to engage with cessation services, or beliefs shaping these intentions. Methods: Five semi-structured focus groups and two interviews were conducted with adults who use non-cigarette tobacco in England (N = 25). Topic guides covered harm perceptions, interest in quitting, and knowledge of, interest in, and barriers to using services for quitting. Data were prepared and analyzed using iterative categorization and abductive thematic analysis. Results: Participants often recognized health harms and some reported experiencing addiction. Many participants had never considered quitting, whereas others described multiple attempts. Interest in quitting was shaped by perceptions of addiction and socio-cultural roles of non-cigarette tobacco. Participants were rarely asked about non-cigarette tobacco use by healthcare professionals and were unaware of whether cessation services could support non-cigarette tobacco use. Although some expressed interest in using services, many preferred to rely on willpower and online support, or felt insufficiently dependent to use services. Participants suggested improving awareness of support through community outreach and routinely asking about all forms of tobacco use in healthcare settings. Conclusions: People who use non-cigarette tobacco show varied interest in quitting, which appears to be shaped by perceived addiction and social factors. Limited awareness of cessation support and low engagement by healthcare professionals may represent missed opportunities for intervention. Implications: Encouraging healthcare professionals to ask about non-cigarette tobacco use, increasing visibility of cessation services, and providing better online resources could improve engagement and cessation support for people who use non-cigarette tobacco.

Introduction: It is important to investigate whether declines in smoking initiation with age are less pronounced among people with mental health problems than among those without. If smoking is used to cope with new mental health symptoms, initiation may occur at older ages in this group. Methods: Using cross-sectional data from 29 845 adults aged 16-45 in Great Britain (surveyed October 2020–June 2023), we examined whether associations between age and (i) ever smoking prevalence and (ii) length of abstinence (among those who quit >1 year ago; n = 4315) differed by past-month psychological distress or history of a mental health condition (MHC). Results: Approximately half of those reporting distress (46.5% [95%CI = 45.5-47.5]) or history of a MHC (52.2% [51.1-53.2]) had ever smoked, compared with one-third of those without (35.1% [34.2-35.9] and 32.6% [31.8-33.4], respectively). Ever smoking prevalence was higher among those with mental health problems across all ages and increased more steeply between ages 16-25 among those reporting distress before plateauing. Among former smokers, mean abstinence was shorter with distress (6.8 [SD = 5.5]) or history of a MHC (7.1 [5.6]) than without (8.0 [5.9] and 7.9 [5.9], respectively), though age-related increases in abstinence duration were similar. Conclusions: Ever smoking prevalence was consistently higher in people with mental health problems and may have increased more steeply in early adulthood among those with past-month distress. Age-related abstinence patterns were similar, but those with mental health problems had shorter average abstinence durations. Patterns may reflect higher initiation rates earlier in life and greater relapse, rather than later initiation. Implications: Smoking prevention and cessation efforts in Great Britain should prioritize people with mental health problems, among whom smoking remains more prevalent and durations of abstinence are shorter. The concentration of smoking initiation before age 30 underscores the importance of interventions during young adulthood, and the potential for the smoke-free generation policy to reduce the burden of smoking in this priority group.

Background and aims: Alcohol consumption at high levels is common among people experiencing homelessness and contributes to inequalities. In relative terms these individuals are underrepresented in substance use services. This study captured common trajectories and identified barriers and facilitators to accessing treatment among a group of people currently experiencing homelessness and who have used or have been eligible for alcohol treatment. Methods: Qualitative study in which we conducted 32 semi‐structured ‘journey‐mapping’ interviews with individuals currently experiencing homelessness and currently or previously using alcohol harmfully. Interviews were conducted in London homeless centres (UK), audio‐recorded and transcribed verbatim. We used a life course‐informed, journey‐mapping thematic analysis (with elements of reflexive thematic analysis) to capture how participants made sense of their trajectories of alcohol use and recovery. Results: Overall, we generated six themes describing participants' journeys: ‘Early access & exposure to alcohol’, ‘Drivers and vulnerabilities for heavy alcohol use’, ‘Sustained heavy alcohol use: coping mechanisms, consequences and compounding challenges’, ‘Systemic, interpersonal and environmental barrier to recovery’, ‘Internal path towards recovery: growth, relationships and motivation’ and ‘Recovery through external support systems and structures’. Participants often situated the onset of heavy drinking in childhood trauma and adverse family environments, describing alcohol as a coping mechanism for emotional pain. Homelessness was narrated as both a consequence and driver of drinking, with environmental factors such as sleeping rough and shared identities around heavy drinking reinforcing consumption. Recovery was portrayed as a deeply personal process requiring internal motivation, autonomy and supportive relationships. Barriers of accessing care included long waiting times, administrative hurdles and negative service experiences, while facilitating factors comprised stable housing, personalised care and peer support. Transformative shifts in perspective and the development of self‐compassion were described as pivotal turning points. Conclusions: Among people experiencing homelessness, heavy drinking appears to be commonly rooted in childhood trauma and adverse family environments, with homelessness described as both a consequence and a reinforcing driver of alcohol use. Recovery is portrayed as a highly personal process supported by stable housing, personalised care and meaningful relationships, including peer support.

Introduction: An increasing proportion of adults in Great Britain who smoke cigarettes do not smoke every day. This study examined whether people smoking non-daily differ from those smoking daily in their quitting behaviour, use of support, and quit success. Methods: We analysed cross-sectional (n=18,845) and prospective (n=2,648) data from a population study of adults who smoke cigarettes in Great Britain conducted 2020-2026. Smoking frequency was categorised as non-daily/daily. Outcomes included quit attempts in the past 12 months (cross-sectional) and during 12-month follow-up (prospective), characteristics of the most recent attempt (planned/unplanned; abrupt/gradual), use of evidence-based cessation support, and quit success. Logistic regression models adjusted for sociodemographic characteristics, year, and other relevant covariates. Results: Participants who smoked non-daily were more likely than those who smoked daily to report a quit attempt, both cross-sectionally (adjusted OR [aOR]=1.27[95%CI=1.17-1.39]) and prospectively (aOR=1.45[1.14-1.84]). Among those who tried to quit, attempts were similarly likely to be planned or abrupt. Overall use of evidence-based cessation support, and e-cigarette use specifically, was similar between groups; however, those who smoked non-daily were less likely to report using prescription nicotine replacement therapy (cross-sectional aOR=0.55[0.38-0.81]; prospective aOR=0.27[0.12-0.64]). There was no clear evidence that adults who smoked non-daily were more or less likely to achieve quit success after full adjustment (aOR=1.10[0.71-1.71]). Conclusions: Adults who smoke non-daily appear more likely to attempt quitting than those who smoke daily. Once an attempt is made, their approach, use of support, and short-term success are broadly similar, although those smoking non-daily report lower uptake of prescription pharmacotherapy.

We are three women working across behavioural and social science, at different stages of our careers, who between us have spoken at, chaired, and organised a considerable number of international conferences. This piece grew out of a conversation between us at a recent conference, and it is written for people who organise or chair scientific meetings.

Smoking rates are up to four times higher among people experiencing homelessness compared to the housed population and how to support them to quit is unclear. To test the effectiveness and cost-effectiveness of providing e-cigarettes to people accessing homeless support services to stop smoking. To explore implementation fidelity, contextual influences and mechanisms of change. A two-arm cluster randomised controlled trial with cost-effectiveness and mixed-methods process evaluation. Setting and participants: Thirty-two homeless centres (clusters) across Great Britain. Participants were aged 18+ years and known by centre staff to smoke. Sixteen staff and 31 participants in electronic cigarette centres completed qualitative interviews. Clusters were randomised (1 : 1) to electronic cigarettes or usual care prior to staff training. Electronic cigarette participants received a refillable electronic cigarette, 4 weeks' supply of e-liquid and a fact sheet. Usual care participants received very brief advice on smoking, a support leaflet and signposting to Stop Smoking Service. Primary outcome: Carbon-monoxide-verified sustained smoking abstinence from 2 weeks post baseline to 24 weeks. Secondary outcomes: Carbon-monoxide-verified 7-day point prevalence abstinence, < 50% smoking reduction, intervention costs, quality-adjusted life-years, implementation fidelity and mechanisms of change. Sixteen centres were randomised to electronic cigarettes (n = 239 participants) and 16 to usual care (n = 238 participants). In usual care, one participant died, and one withdrew consent. Final sample analysed: n = 239 (electronic cigarette); n = 236 (usual care). Sustained 24-week carbon-monoxide-verified smoking cessation rates were 5/239 (2.1%) with electronic cigarettes versus 2/236 (0.8%) with usual care (adjusted risk ratio 2.43, 95% confidence interval 0.51 to 11.64); 7-day point prevalence abstinence at 24 weeks was 15/239 (6.3%) with electronic cigarettes versus 5/236 (2.1%) with usual care (adjusted risk ratio 2.95, 95% confidence interval 1.05 to 8.29). Smoking reduction (< 50%) at 24 weeks was 83/239 (34.7%) with electronic cigarettes versus 40/236 (17%) with usual care (adjusted risk ratio 2.02, 95% confidence interval 1.44 to 2.84). Four adverse events were reported in the electronic cigarette arm; three electronic cigarette-related and not serious; one serious and not electronic cigarette-related. Mean per participant intervention costs were £92 (standard error £0) for electronic cigarettes and £50 (standard error £0) for usual care. Mean total costs were £3859 (standard error £441) versus £2716 (standard error £386) in electronic cigarette and usual care groups, respectively. Quality-adjusted life-years were estimated at 0.303 (standard error 0.008) for electronic cigarettes and 0.295 (standard error 0.010) for usual care. From National Health Service and Personal Social Services perspective, the electronic cigarette arm was £1267 (95% confidence interval £219 to £2347) more costly and yielded 0.007 (95% confidence interval -0.016 to 0.033) more quality-adjusted life-years than usual care. The incremental cost-effectiveness ratio was £181,000 per quality-adjusted life-year gain. Electronic cigarette intervention was delivered with high fidelity with no variation by centre size or location, although staff capacity and resourcing were barriers to implementation. Quit enablers included high capability to use electronic cigarettes, support from friends/family and increased motivation following smoking reduction. Barriers included lack of satisfaction with electronic cigarettes compared with smoking, a strong smoking culture at centres and staff deprioritising tobacco-related harm. Low quit rates resulted in insufficient power to detect an effect on the primary effectiveness and cost-effectiveness outcomes, leading to uncertainty. Electronic cigarettes showed no effectiveness for 24 weeks' sustained smoking abstinence; 7-day point prevalence abstinence and smoking reduction were possible, and staff can support the intervention. Longer-term and potentially different types of support and systems change are needed to support sustained abstinence. This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme as award number NIHR132158.