{"paper_id":"c83f119c-3189-4f2f-b3b5-ad883fbee33c","body_text":"1 \n \nEstimating young adult uptake of smoking by area across the UK \n \nSarah E. Jackson1,2, Harry Tattan-Birch1,2, Nicholas S Hopkinson,3 Jamie Brown,1,2 Lion Shahab1,2, \nLaura Bunce,4 Anthony A Laverty,5 Deborah Arnott4 \n \n1 Department of Behavioural Science and Health, University College London, London, UK \n2 SPECTRUM Consortium, Edinburgh, UK \n3 National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK \n4 Action on Smoking and Health, UK \n5 School of Public Health, Imperial College London, London, UK \n \nCorresponding author: Dr Sarah Jackson, Department of Behavioural Science and Health, \nUniversity College London, 1-19 Torrington Place, London WC1E 7HB, UK. s.e.jackson@ucl.ac.uk \n+44 (0)207 679 8312 \n \n  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2 \n \nAbstract \nBackground: There is majority support in parliament and across the United Kingdom (UK) to \nimplement a ‘smokefree generation’ policy which would increase the legal age of sale of tobacco \nfrom 18 by one year each year from 2027 onwards, such that people born on or after 1 January \n2009 could never legally be sold tobacco. To explore the potential impact this policy could have, we \nestimated the number of young adults (18–25y) currently taking up smoking each year by area \nacross the UK. \nMethods: Using data from the Office for National Statistics (ONS), Annual Population Survey \n(APS), and Smoking Toolkit Study (STS), we estimated the total number of 18–25-year-olds in the \nUK taking up smoking each year, based on national estimates of population size (ONS) and the \nproportion who reported ever having been a regular smoker (STS). We used local data on adult \nsmoking rates (APS) to apportion the national estimated number of young adults taking up smoking \nto specific areas. \nResults: Around 127,500 18–25-year-olds in the UK start smoking regularly each year (349 each \nday); 105,700 each year (290 each day) in England, 11,500 (32) in Scotland, 6,500 (18) in Wales, \nand 3,800 (10) in Northern Ireland. Estimates of uptake varied across localities: for example, North \nEast Lincolnshire had the highest proportion of young adults taking up smoking each year (3.96%) \nand Wokingham had the lowest (0.85%). \nConclusions: Despite reductions in smoking prevalence over recent decades, hundreds of young \nadults in the UK start smoking every day. Data on rates of uptake among individual local authorities \ncan be used to focus attention locally prior to the introduction of new age of sale laws. \n \nKey words: smoking; initiation; region; constituency; Great Britain; England; Wales; Scotland; \nNorthern Ireland  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n3 \n \nIntroduction \nTobacco smoking is uniquely harmful and remains a leading cause of disease, disability, and \npremature death globally.1,2 Two out of every three people who do not manage to quit will die from \ntheir smoking.3 \nMost people take up smoking when they are young,4,5 underestimating the short-term risks and not \nexpecting it to become a life-long habit.6 However, they quickly become addicted7 and find it difficult \nto quit in later life. The majority (54%) of smokers in England want to stop8 and three-quarters say \nthey would never have started if they had the choice again.9 Starting to smoke at any age has \nsevere health consequences in the long run, but these are particularly pronounced among those \nwho start young.10 \nTo reduce the number of young adults taking up smoking and alleviate the burden of smoking-\nrelated death and disease for the next generation, the United Kingdom (UK) Government intended \nto implement a ‘smokefree generation’ policy which would increase the legal age of sale of tobacco \nfrom 18 by one year each year from 2027 onwards, such that people born on or after 1 January \n2009 would never legally be sold tobacco.11 This policy was endorsed by the Chief Medical Officers \nof all four UK nations (England, Wales, Scotland, and Northern Ireland)12 and has widespread \npublic13 and parliamentary14 support. A bill to enact the legislation was progressing through \nparliament – and passed a second reading by a majority of 31614 – but did not pass into law before \na snap election was called in May 2024. Both the party of government and the opposition have \ncommitted to bringing the legislation back after the election. \nTo offer insight into the potential impact this policy could have, this study aimed to estimate the \nnumber of young adults (18–25y) currently taking up smoking each year by local area across the \nUK. \n \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n4 \n \nMethods \nEstimating the number of 18–25-year-olds in the UK taking up smoking  \nThe initial analysis was based on data from the Smoking Toolkit Study, a nationally representative \nmonthly cross-sectional survey of adults (≥ 16 years) in Great Britain.15,16 We analysed data from \n7,080 respondents aged 16–25 years surveyed between January 2022 and January 2024. \nSmoking status was assessed by asking participants which of the following best applied to them: \n(a) I smoke cigarettes (including hand-rolled) every day; (b) I smoke cigarettes (including hand-\nrolled), but not every day; (c) I do not smoke cigarettes at all, but I do smoke tobacco of some kind \n(e.g., pipe, cigar or shisha); (d) I have stopped smoking completely in the last year; (e) I stopped \nsmoking completely more than a year ago; (f) I have never been a smoker (i.e., smoked for a year \nor more). Those who responded (a)–(e) were considered ever regular smokers. \nWeighted logistic regression was used to model ever regular smoking by age, with age modelled \nnon-linearly using restricted cubic splines (with three knots placed at the 5th, 50th, and 95th \npercentiles). We used this model to estimate the proportion of 17- and 25-year-olds who have ever \nregularly smoked, incorporating information from all participants aged 16–25 (rather than just those \naged 17 and 25). \nWe assumed a constant rate of uptake of smoking across each year of ageing, which we calculated \nas:  \n(proportion of 25-year-olds who have ever regularly smoked – proportion of 17-year-olds \nwho have ever regularly smoked) / 8 years = rate of uptake \nUsing 2021 Office for National Statistics mid-year estimates for population size,\n17 we then \nestimated the number of 18–25-year-olds in the UK who start smoking regularly each year \n(assuming the rate of uptake is the same as the Smoking Toolkit Study estimate for Great Britain) \nas:  \nrate of uptake * number of 18–25-year olds = number of 18–25-year-olds taking up smoking \neach year \nFor this estimate, we rounded percentages to one decimal place and numbers >1,000 to the \nnearest 1,000. \nEstimating geographic differences in the number of 18–25-year-olds taking up smoking \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n5 \n \nThis UK estimate was then split across geographical areas according to their adult smoking \nprevalences, based on the assumption that there was likely to be a greater proportion of young \nadults taking up smoking in areas that have more adult smokers (i.e., regional differences in \nsmoking uptake would be proportionate to regional differences in adult smoking prevalence). \nWe obtained data on adult (≥ 18 years) and young adult (18–25 years) population sizes and adult \nsmoking prevalence in the UK, overall and by nation (England, Scotland, Wales, and Northern \nIreland), government office region in England, and upper-tier local authority and unitary authority \nareas of England, Wales, Scotland, and Northern Ireland. We used the 2021 Office for National \nStatistics mid-year estimates for population size17 and the 2022 Annual Population Survey \nestimates of smoking prevalence.18  \nFor each locality, we calculated the number of adult smokers (local adult population size x local \nsmoking prevalence) and the proportion of UK adult smokers that this represented (local number of \nadult smokers / total number of adult smokers in the UK). We then apportioned our estimate of the \ntotal UK number of new young adult smokers according to the proportion of the total adult smoking \npopulation in that locality. We calculated the local number (total number of young adults in the UK \ntaking up smoking each year x local proportion of UK adult smokers) and proportion (local number \nof young adults taking up smoking each year / local young adult population size) of young adults \ntaking up smoking each year. \nThe analyses were not pre-registered and should be considered exploratory. \n \nResults \nThe Smoking Toolkit Study analysis suggested the prevalence of ever regular smoking increases \nfrom 21.9% at 17 years to 37.7% by age 25. Assuming a constant rate of uptake, this equates to \n2.0% uptake across any year of aging between ages 18 to 25 ((37.7%-21.9%) / 8 years). There are \n~6,375,000 people aged 18–25 in the UK.17 We therefore estimated that 127,500 (6,375,000 * \n2.0%) 18–25-year-olds in the UK start smoking regularly each year. \nThe estimated proportion of 18–25-year-olds who take up smoking each year is presented as a \nheat map by local authority and unitary authority areas across the UK in Figure 1. Tables with \ndaily, weekly, monthly, and annual figures for each UK nation and region in England are provided in \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n6 \n \nTable 1; corresponding estimates for local authority and unitary authority areas are available in the \nSupplementary File. \nOf the 6.375 million 18–25-year-olds across the UK, an estimated 349 start to smoke each day: 290 \nin England, 32 in Scotland, 18 in Wales, and 10 in Northern Ireland. There was substantial variation \nin the proportion of young adults taking up smoking across localities. North East Lincolnshire and \nTorbay had the highest rates of uptake (3.96% and 3.90% annually): each month, 42 from a \npopulation of 13,000 in North East Lincolnshire and 33 from a population of 10,000 in Torbay \nstarted to smoke regularly. Uptake was lowest in Wokingham and York (0.85% and 0.87% \nannually), with 10 and 22 young adults starting to smoke regularly each month from populations of \n14,000 and 31,000, respectively. \n  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n7 \n \n \n \nFigure 1. Estimated proportion of young adults aged 18–25 who start smoking in the UK \neach year.  \nFor each locality, data shown are the estimated total number of young adults taking up smoking in \nthe UK each year apportioned according to the proportion of the total adult smoking population in \nthat locality, divided by the local young adult population size.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n8 \n \nTable 1. Estimates of smoking uptake among 18–25-year-olds by UK nation and region in England \n \nAdult \npopulation1 \nSmoking \nprevalence, \n%2 \nNo. of \nadult \nsmokers3 \n% of UK \nsmokers \nYoung \nadult \npopulation  \n(18–25y)1 \nNumber of new smokers4 \nper… \n \nYear Month Week Day \n          \nUnited Kingdom 53,188,000 12.9 6,861,300 100.0 6,375,000 127,500 10,625 2,452 349 \n           \nNation          \n   England 44,775,000 12.7 5,686,400 82.9 5,392,000 105,668 8,806 2,032 290 \n   Scotland 4,455,000 13.9 619,200 9.0 516,000 11,507 959 221 32 \n   Wales 2,489,000 14.1 350,900 5.1 291,000 6,521 543 125 18 \n   Northern Ireland 1,470,000 14.0 205,700 3.0 177,000 3,823 319 74 10 \n           \nRegion in England          \n   East Midlands 3,890,000 14.0 544,600 7.9 480,000 10,120 843 195 28 \n   East England 5,018,000 13.2 662,300 9.7 546,000 12,308 1,026 237 34 \n   London 6,904,000 11.7 807,800 11.8 925,000 15,011 1,251 289 41 \n   North East 2,122,000 13.1 278,000 4.1 255,000 5,165 430 99 14 \n   North West 5,860,000 13.4 785,300 11.5 715,000 14,593 1,216 281 40 \n   South East 7,358,000 11.5 846,100 12.3 826,000 15,724 1,310 302 43 \n   South West 4,626,000 11.9 550,500 8.0 526,000 10,229 852 197 28 \n   West Midlands 4,663,000 13.4 624,800 9.1 576,000 11,610 968 223 32 \n   Yorkshire and the \nHumber 4,335,000 13.1 567,900 8.3 543,000 10,553 879 203 29 \n          \n1 Office for National Statistics 2021 mid-year population estimates. \n2 Annual Population Survey, 2022. \n3 Adult population x smoking prevalence. \n4 Estimated number of 18–25-year-olds taking up smoking. \nNote: estimated numbers of new smokers by UK nation or region in England do not sum precisely to totals due to rounding. \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n9 \n \nConclusions and limitations \nThis analysis shows that despite reductions in smoking prevalence over recent decades,18 \nhundreds of young adults in the UK start smoking every day. Raising the legal age of sale is likely \nto be an effective measure to reduce this, based on evidence that increases from 16 to 18 in the \nUK in 200719–21 and increases to 21 in the US22–26 were associated with decreases in smoking \namong age groups that could not legally able to buy tobacco. Steadily increasing the legal age of \nsale further will likely reduce the chance of people becoming addicted at any point in life, given \nolder age of smoking initiation is associated with lower levels of lifetime nicotine dependence.27 As \nwell as the overall scale of uptake, the data here on rates of uptake among individual local \nauthorities can be used to focus attention locally on the value to their communities of the national \npolicy to raise the age of sale to help prevent smoking initiation at any age.  \nIt is important to acknowledge that this type of estimation has limitations. The data presented are \nextrapolated from survey data, so are necessarily approximate. For some local and unitary \nauthority areas, Annual Population Survey estimates of smoking prevalence were based on small \nsamples so may be unreliable (for reference, sample sizes are provided in the Supplementary File). \nThe Smoking Toolkit Study does not cover Northern Ireland, so the rate of uptake was estimated \nbased on data collected in Great Britain, rather than the whole of the UK. We also assumed that \ncurrent population sizes were similar to 2021 and that local variation in rates of smoking uptake \nwould correspond to variation in adult smoking rates. \n \n \n  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n10 \n \nReferences \n1  World Health Organization. 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Community reductions in \nyouth smoking after raising the minimum tobacco sales age to 21. Tob Control 2016; 25: 355–\n359. \n23  Friedman AS, Buckell J, Sindelar JL. Tobacco-21 laws and young adult smoking: quasi-\nexperimental evidence. Addict Abingdon Engl 2019; 114: 1816–1823. \n24  Glover-Kudon R, Gammon DG, Rogers T, Coats EM, Loomis B, Johnson L et al. Cigarette and \ncigar sales in Hawaii before and after implementation of a Tobacco 21 Law. Tob Control 2021; \n30: 98–102. \n25  Friedman AS, Wu RJ. Do Local Tobacco-21 Laws Reduce Smoking Among 18 to 20 Year-\nOlds? Nicotine Tob Res 2020; 22: 1195–1201. \n26  Hansen B, Sabia JJ, McNichols D, Bryan C. Do tobacco 21 laws work? J Health Econ 2023; \n92: 102818. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n12 \n \n27  Hu M-C, Davies M, Kandel DB. Epidemiology and Correlates of Daily Smoking and Nicotine \nDependence Among Young Adults in the United States. Am J Public Health 2006; 96: 299–308. \n  \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n13 \n \nDeclarations  \nEthics approval \nEthical approval for the STS was granted originally by the UCL Ethics Committee (ID 0498/001). \nThe data are not collected by UCL and are anonymised when received by UCL. \nFunding \nThis work was supported by Cancer Research UK (PRCRPG-Nov21\\100002). For the purpose of \nOpen Access, the author has applied a CC BY public copyright licence to any Author Accepted \nManuscript version arising from this submission. \nDeclaration of interests \nJB has received unrestricted research funding from Pfizer and J&J, who manufacture smoking \ncessation medications. LS has received honoraria for talks, unrestricted research grants and travel \nexpenses to attend meetings and workshops from manufactures of smoking cessation medications \n(Pfizer; J&J), and has acted as paid reviewer for grant awarding bodies and as a paid consultant for \nhealth care companies. All authors declare no financial links with tobacco companies, e-cigarette \nmanufacturers, or their representatives. \n \n \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)\nThe copyright holder for this preprint this version posted June 25, 2024. ; https://doi.org/10.1101/2024.06.25.24309461doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}