Assessing dual nicotine use in Spain: Transition to cessation or sustained consumption?

Background Spain’s aging population, coupled with the persistent prevalence of smoking, places increasing pressure on the country’s healthcare system. Novel nicotine products, such as e-cigarettes and heated tobacco products (HTPs), may serve as an adequate, less harmful alternative and cessation tool for smokers. However, critics are concerned about the risk of uptake among never-smokers and high rates of dual use of both conventional cigarettes and alternatives. Therefore, it is crucial to determine whether dual use presents a transitional phase toward cessation or if alternatives are a complementary nicotine source for smokers. The outcome of this assessment should guide whether regulations should harmonize or differentiate nicotine products based on the relative harm of each product. Methods We conducted a cross-sectional study among 1,329 Spanish nicotine users on their history of consumption. This large dataset allowed us to track each respondent’s consumer journey from initiation to switching behavior to cessation. We also applied a linear regression model to determine the predictors of exclusive smoking behavior or dual use. Results The vast majority of consumers start their nicotine journey with conventional cigarettes. When smokers take up non-combustible alternatives (NCAs) and become dual users, they gradually replace cigarettes with NCAs in terms of frequency and intensity of use. Observing a sample of consumers using nicotine products consistently for the past 5 years shows that dual users not only replace harmful cigarettes with NCAs but also that their total nicotine consumption declines. Among current and former HTP users, 44% reported using HTPs to quit or reduce their smoking, while 16% of e-cigarette users expressed the same motivation. In addition, 43% of all users of nicotine products stated that they would consider quitting smoking if the regulatory or tax framework for tobacco products were to change. Conclusions The findings suggest that governments should implement policies that incentivize smokers to switch to less harmful alternatives, even if they initially become dual users. By recognizing dual use as part of the cessation journey, policymakers can develop strategies to better support smokers in reducing harm, particularly the most vulnerable smokers. Policymakers can better support smokers in transitioning away from traditional cigarettes and reduce the overall public health burden of smoking by integrating fiscal, regulatory, and awareness-raising measures.