Choice and Variety-Seeking of E-liquids and Flavor Categories by New Zealand Smokers Using an Electronic Cigarette: A Longitudinal Study

Exploring the opinions and potential impact of unflavoured e-liquid on smoking cessation among people who smoke and smoking relapse among people who previously smoked and now use e-cigarettes: findings from a UK-based mixed methods study

BACKGROUND

Although electronic cigarettes (e-cigarettes) appear to be effective in helping people who smoke to stop smoking, concerns about use of e-cigarettes among young people have led to restrictions on non-tobacco flavoured e-liquids in some countries and some US states. These restrictions could reduce the appeal of these products to non-smoking youth but could have negative consequences for people who smoke or use e-cigarettes.

METHODS

In this mixed methods study, we recruited UK adults who smoked or used to smoke and subsequently vaped to explore their opinions of unflavoured e-liquids and their beliefs about how they would be impacted by hypothetical e-liquid flavour restrictions. Participants trialled an unflavoured e-liquid instead of their usual nicotine product for four hours and completed a survey and an online interview.

RESULTS

Using Interpretive Phenomenological Analysis and graphically presented data, we found differences in participants' opinions of unflavoured e-liquid. If only unflavoured, tobacco flavoured, and menthol flavoured e-liquids remained on the UK market, some people who smoke or vape may be unaffected, but some may relapse to smoking or continue smoking. Despite most wanting to prevent young people from initiating vaping, participants had varying opinions on whether flavour restrictions would be an effective method.

CONCLUSIONS

The findings highlight that people who smoke and vape could be impacted by flavour restrictions in a range of ways, some of which could have a potential adverse impact on harm reduction efforts in the UK (e.g., by making smoking more appealing than vaping).

Smoking, vaping and drinking: A qualitative analysis of Aotearoa New Zealand young adults who tried e-cigarettes to stop smoking tobacco

BACKGROUND AND AIM

Social practices such as smoking-drinking co-use often go 'hand-in-hand', linked by the coordination of materials, skills and meanings. However, the experience of using e-cigarettes while drinking among people who smoke (and drink) remains underexplored. We used social practice theory to show how smoking, vaping and drinking intersect and to explain how vaping created two new social practices among people who tried e-cigarettes to stop smoking: 'vaping-drinking' co-use and 'smoking-vaping-drinking' poly-use.

METHODS

We conducted five in-depth interviews over 18-24 weeks during 2018-19, with each of nine Aotearoa New Zealand young adults aged 20-29 years. Participants smoked daily, did not regularly use e-cigarettes at entry and wished to try vaping to stop smoking. We analysed participants' reports of smoking or vaping while drinking using thematic analysis.

RESULTS

Individual participants reported both co-use and poly-use occasions throughout the study. Vaping-drinking co-use arose from practice 'replacement' processes, where vaping fully substituted smoking. Smoking-vaping-drinking poly-use arose from 'adjacency' processes where vaping complemented smoking. Participants used both processes flexibly over time, which required new skills in material, temporal, pleasure and social coordination to try to recreate valued meanings of comfort, security and communality associated with well-established smoking-drinking practices. Unsuccessful coordination attempts maintained smoking-drinking co-use.

CONCLUSION

Among Aotearoa New Zealand young adult smokers who want to use vaping to stop smoking, drinking occasions may help to maintain existing smoking-drinking practices and facilitate the development of vaping-drinking co-use and smoking-vaping-drinking poly-use practices, potentially prolonging individuals' exposure to smoking.

An exploration of flavours in studies of e-cigarettes for smoking cessation: secondary analyses of a systematic review with meta-analyses

AIMS

To estimate associations between e-cigarette flavour and smoking cessation and study product use at 6 months or longer.

METHODS

Secondary analysis of data from a living systematic review, with meta-analyses and narrative synthesis, incorporating data up to January 2022. Included studies provided people who smoked combustible cigarettes with nicotine e-cigarettes for the purpose of smoking cessation compared with no treatment or other stop smoking interventions. Measurements included smoking cessation and study product use at 6 months or longer reported as risk ratios (RR) with 95% confidence intervals (CI); and flavour use at any time-points.

RESULTS

We included 16 studies (n = 10 336); 14 contributed to subgroup analyses and 10 provided participants with a choice of e-cigarette flavour. We judged nine, five and two studies at high, low and unclear risk of bias, respectively. Subgroup analyses showed no clear associations between flavour and cessation or product use. In all but one analysis, tests for subgroup differences resulted in I2 values between 0 and 35%. In the comparison between nicotine e-cigarettes and nicotine replacement therapy (NRT) (I2  = 65.2% for subgroup differences), studies offering tobacco flavour e-cigarettes showed evidence of a greater proportion of participants still using at 6 months or longer (RR = 3.81; 95% CI = 1.45-10.05; n = 1181; I2  = 84%), whereas there was little evidence for greater 6-month use when studies offered a choice of flavours (RR = 1.44; 95% CI = 0.80-2.56; n = 454; I2  = 82%). However, substantial statistical heterogeneity within subgroups makes interpretation of this result unclear. In the 10 studies where participants had a choice of flavours, and this was tracked over time, some switching between flavours occurred, but there were no clear patterns in flavour preferences.

CONCLUSIONS

There does not appear to be a clear association between e-cigarette flavours and smoking cessation or longer-term e-cigarette use, possibly due to a paucity of data. There is evidence that people using e-cigarettes to quit smoking switch between e-cigarette flavours.

Correlates of e-cigarette use before and after comprehensive regulatory changes and e-liquid flavour ban among general population

INTRODUCTION

In 2016, the Finnish Tobacco Act was revised to harmonise e-cigarette regulations with the EU Tobacco Products Directive. Unlike before, the sale of nicotine-containing e-liquids was allowed while additional national regulations included, for example, a ban for other than unflavoured and tobacco-flavoured e-liquids. This study examines the correlates of e-cigarette use before and after the comprehensive regulatory change, and characteristics and correlates of flavoured e-cigarette use after the flavour ban in the general Finnish population.

METHODS

Repeated cross-sectional population-based drug surveys for 15-69-year-olds in 2014 (n = 3485; 50% response rate) and in 2018 (n = 3229; 46%). Correlates of e-cigarette use were studied with logistic regression models.

RESULTS

Current e-cigarette use remained infrequent (approximately 2%) and the correlates of e-cigarette use varied only slightly between the study years. In 2018, of past-year e-cigarette users (n = 316), 43% used unflavoured e-liquids, 24% used tobacco and 43% used other flavours, fruits being the most common. In univariate models, demographic variables, smoking and e-cigarette use-related factors were associated with flavoured e-cigarette use. In multivariable models, those who used e-cigarettes to experiment used unflavoured e-cigarettes more likely than other than tobacco flavours (odds ratio 3.00, 95% confidence interval 1.15-7.82).

DISCUSSION AND CONCLUSIONS

In Finland, the regulated entry of nicotine-containing e-liquids to retail sales has not led to increased e-cigarette use in the general population. After the flavour ban, other than tobacco-flavoured e-cigarette use still occurs. The use of flavoured e-cigarettes is associated with reasons for e-cigarette use. Flavoured e-cigarette use and its correlates warrant further monitoring.

A Descriptive Analysis of Transitions from Smoking to Electronic Nicotine Delivery System (ENDS) Use: A Daily Diary Investigation

OBJECTIVES

We aimed to examine patterns in smoking and electronic nicotine delivery system (ENDS) use over an extended period of time (up to 20 weeks) in people who smoked and who had never previously made a successful quit attempt using an ENDS.

DESIGN AND SETTING

We conducted a longitudinal mixed-methods study in Dunedin, New Zealand, during 2018 and 2019.

PARTICIPANTS

Purposively selected participants (N = 45; age (≥18 years), gender, ethnicities, cigarettes/day) who wished to quit smoking.

INTERVENTIONS

Participants were provided with a second-generation ENDS device (vape pen or starter "tank" device) at the start of their quit attempt, and asked to complete smartphone-based daily diary surveys assessing smoking and ENDS use.

OUTCOME MEASURES

Sunburst plots and a sequence plot were used to describe weekly and daily patterns of smoking and ENDS use (smoking only, ENDS use only, dual use, abstinent).

RESULTS

The most frequently reported movements among participants, classified according to their study week behaviour, occurred between dual use and exclusive ENDS use (and vice versa). A smaller group reported moving from dual use to exclusive smoking (and often back to dual use), and a small number reported moving between abstinence and different ENDS and smoked tobacco usage behaviours. Data visualisations focussing on those participants who had provided data during each of weeks 9-12 indicate that only a minority reported sustained dual use; instead, most participants indicated varied smoked tobacco and ENDS use, which included periods of dual use.

CONCLUSIONS

The considerable variety observed within and between study participants suggests that high variability is typical rather than exceptional. Transitions from smoking to ENDS use may involve considerable periods of dual use, which is likely to be dynamic and potentially sustained over several months.