Smokers’ and ex-smokers’ understanding of electronic cigarettes: a qualitative study

A Descriptive Analysis of Beliefs About Nicotine and Switching to Noncombustibles Among Adults Who Smoke Cigarettes and Believe Nicotine Causes Cancer

Introduction: Many people who smoke cigarettes report believing that nicotine causes cancer, a misperception that may reduce interest in switching to noncombustible nicotine products. Quantitative survey questions do not capture how this population thinks about nicotine and switching to noncombustible products. Methods: This study used an online convenience sample of 193 US adults who smoke cigarettes and reported that nicotine causes cancer. Respondents were asked if they thought nicotine was harmful (and why or why not) and if they would consider switching to a noncombustible product (and why or why not). Inductive and deductive coding were used, and descriptive statistics are reported. Results: Descriptions of nicotine directly causing disease (61%) were more common than descriptions of nicotine causing addiction to a harmful product (8%). One-third expressly stated that nicotine causes cancer, and 21% that nicotine causes lung disease. Interest in switching was moderate (mean 47.4 out of 100). When asked about switching, 34% described enjoying their current smoking experience, 23% described a perceived health benefit, 16% described a health concern, and 11% worried that switching would not address nicotine addiction. Discussion: Adults who smoke commonly perceived nicotine as a direct cause of cigarette-related disease, and harm and addictiveness perceptions were often mentioned as reasons for interest or disinterest in switching to a noncombustible. Future studies could explore strategies for correcting nicotine misperception, stigma related to addiction, and common concerns related to health as well as user experience.

How do Smokers in a Snus-Prevalent Society Consider E-cigarettes, Snus, and Nicotine Replacement Therapy Products as Relevant Replacements for Cigarettes in the Event They Should Stop Smoking?

INTRODUCTION

Around 50 percent of the tobacco in Norway is consumed in the form of snus, a smokeless oral tobacco. We examined Norwegian smokers' openness, and thereby the potential reach, to use e-cigarettes, nicotine replacement therapy products (NRT), and snus in the event of quitting smoking, in a society where snus use is common.

METHODS

Using data from an online survey of 4073 smokers from 2019 to 2021, we calculated predicted probabilities of smokers' being open, undecided, and not open to use e-cigarettes, snus, and NRT in the event they should quit smoking.

RESULTS

Among daily smokers, the probability of being open to use e-cigarettes in the event of quitting smoking was .32. The corresponding probabilities for using snus and NRT were .22 and .19. Snus was the product with the highest probability of not being open (.60). NRT had the highest probability of being undecided (.39). Among smokers who had never used e-cigarettes or snus, the probabilities of being open were .13 for e-cigarettes, .02 for snus and .11 for NRT.

CONCLUSIONS

In a snus-friendly norm climate where smokers have traditionally used snus as an alternative to cigarettes, the probability of using e-cigarettes in the event of smoking cessation was higher compared to both snus and NRT. However, among smokers who had never used e-cigarettes or snus, the likelihood of being open to use of NRT was similar to e-cigarettes, and higher than snus, which suggests that NRT may still play a role in smoking cessation.

IMPLICATIONS

In a snus-prevalent country in the endgame phase of the cigarette epidemic, where robust infrastructure for tobacco control in combination with the availability of snus has reduced smoking to a minimum, the remaining smokers seem to prefer e-cigarettes to snus if they should quit smoking. This indicates that availability of several nicotine alternatives might increase the likelihood of a future product replacement within the small group of remaining smokers.

Facilitators and barriers for harm reduction after first use of novel nicotine delivery devices: a qualitative investigation of cigarette smokers

BACKGROUND

Novel nicotine delivery devices (NNDDs) are a safer alternative to combustible tobacco smoking. Understanding what factors can facilitate people who smoke to use NNDDs can inform intervention design and public health messaging. This study aims to explore the facilitators and barriers to NNDD use from the perspective of smokers without prior use, after trialling two NNDDs.

METHOD

UK adults who smoke combustible cigarettes (n = 11) were recruited from a larger quantitative study after trialling two NNDDs, an electronic cigarette and a heated tobacco product (order randomly allocated). Semi-structured interviews were conducted, transcribed and thematically analysed, using the COM-B model of behaviour and NVivo12 pro software.

RESULTS

Five main themes were identified: health knowledge, availability of and accessibility to NNDD products, cost, social acceptance, and NNDD use experience. There was curiosity and interest in the uptake and use of NNDDs, but the absence of centralised product information was identified as a barrier. Other themes were related to the design and functionality of the NNDD products. For example, the e-cigarette with its low maintenance was seen as easier to use than the heated tobacco product, which offered too short a single use duration and was described as 'cumbersome'. Throat discomfort and high anticipated cost were among additional barriers identified for both product types.

CONCLUSION

This study highlights the need for reliable objective information on the health effects of NNDDs compared with combustible cigarettes, which could facilitate their regular use. Product adjustment such as single use duration alignment with combustible cigarette smoking duration may encourage uptake. Interventions offering opportunity for experience of NNDD use and knowledge dissemination of NNDDs could increase motivation to adopt harm reducing behaviours as demonstrated in this study.

The old and familiar meets the new and unknown: patient and clinician perceptions on e-cigarettes for smoking reduction in UK general practice, a qualitative interview study

BACKGROUND AND AIMS

Clinicians could promote e-cigarettes for harm reduction to people who smoke but cannot stop, but many clinicians feel uneasy doing so. In a randomized controlled trial (RCT), primary care clinicians offered free e-cigarettes and encouraged people with chronic diseases who were unwilling to stop smoking to switch to vaping. We interviewed clinicians and patients to understand how to adopt harm reduction in routine practice.

DESIGN

Qualitative analysis nested within an RCT, comprising thematic analysis of semi-structured interviews with primary care clinicians who delivered the trial intervention, and patients who took part.

SETTING

Primary care clinics in England.

PARTICIPANTS/CASES

Twenty-one patients and 11 clinicians, purposively sampled from an RCT.

MEASUREMENTS

We qualitatively explored patients' and clinicians' experiences of: being offered/offering an e-cigarette, past and current perceptions about e-cigarettes and applying a harm reduction approach.

FINDINGS

Four themes captured clinicians' and patients' reported perspectives. These were: (1) concepts of safety/risk, with clinicians concerned about recommending a product with unknown long-term risks and patients preferring the known risks of cigarettes; (2) clinicians felt they were going out on a limb by offering these as though they were prescribing them, whereas patients did not share this view; (3) equating quitting with success, as both patients and clinicians conceptualized e-cigarettes as quitting aids; and (4) unchanged views, as clinicians reported that training did not change their existing views about e-cigarettes. These themes were united by the higher-order concept: 'The old and familiar meets the new and unknown', as a contradiction between this new approach and long-established methods underpinned these concerns.

CONCLUSIONS

A qualitative analysis found barriers obstructing clinicians and patients from easily accepting e-cigarettes for harm reduction, rather than as aids to support smoking cessation: clinicians had difficulty reconciling harm reduction with their existing ethical models of practice, even following targeted training, and patients saw e-cigarettes as quitting aids.

A thematic analysis of smokers' and non-smokers' accounts of E-cigarettes

This study explored smokers' and non-smokers' accounts of E-cigarettes. A total of 51 UK-based participants, 20 men and 31 women, responded to open-ended questions online. Inductive thematic analysis identified that the factors that influence E-cigarette behaviour and opinion in adult smokers and non-smokers are related to social context, informative sources, practical aspects and health implications. Participants presented varying accounts of E-cigarettes, suggesting that individual narratives regarding E-cigarettes are multi-faceted. This is important information for health professionals and policy makers tasked with advising on E-cigarette use.

Within-person longitudinal associations between electronic nicotine delivery systems use and smoking cessation efforts among U.S. continuing adult cigarette smokers

OBJECTIVES

Prior studies that examined the role of electronic nicotine delivery systems (ENDS) use in smoking cessation have shown divergent conclusions. This study examined the time-course of ENDS-associated smoking abstinent behaviors among continuing cigarette smokers who were willing but unable to quit smoking.

METHODS

Data were drawn from the four waves of the Population Assessment of Tobacco and Health Study. Of the 1,684 smokers who tried to quit smoking completely at Wave 1, a total of 1,094 who were continuing smokers until Wave 4 and were not lost to follow-ups comprised the sample. Using generalized linear mixed modeling, we fitted weighted negative binomial regression models to examine within-person associations of ENDS use with quit attempts and number of days abstinent from smoking.

RESULTS

Quit attempt frequency and smoking abstinent days were highest at Wave 1, dropped at Wave 2, and then either increased a little or remained stagnant in later waves. ENDS use to quit smoking was associated with more frequent quit attempts (aIRR=1.67, 95% CI=1.42-1.95) and more abstinent days (aIRR=3.28, 95% CI=2.43-4.44), and the magnitude of such associations became stronger over time. ENDS use was associated with becoming a non-daily smoker among baseline daily smokers.

CONCLUSIONS

ENDS use among continuing smokers may help increase the number of quit attempts and smoking abstinent days. Given that the study sample is continuing smokers who failed in complete smoking cessation, future research would be desirable that evaluates whether such abstinent behaviors sustain and manifest harm reduction with improved health outcomes.

IMPLICATIONS

Smokers increasingly adopt electronic nicotine delivery systems (ENDS) to quit smoking. However, the association of ENDS use with smoking cessation efforts among continuing cigarette smokers who were willing but unable to quit smoking is largely unknown. This study found that quit attempts and smoking abstinent days increased with ENDS use to quit smoking by following up with population-representative continuing smokers. Additionally, this study assessed whether cigarette smokers' abstinent behaviors vary with their use of ENDS by estimating within-person associations with frequent assessments of both exposures and outcomes in a long-term perspective.

The emerging norms of e-cigarette use among adolescents: A meta-ethnography of qualitative evidence

While qualitative research has indicated that adolescents' motivation for e-cigarette use is different than adults', this body of literature has not yet been brought together and synthesised. We reviewed qualitative evidence on perceptions and uses of e-cigarettes in order to explore the emerging norms of vaping among adolescents. We searched five databases for qualitative research in October 2019 with no restrictions on date of publication or data collection. We identified fifteen papers from thirteen studies. Using a meta-ethnographic approach, we identified a spectrum of descriptive and injunctive norms of vaping across the themes of addiction; perceptions of comparative harm; parental perceptions and peer perceptions. We found addiction and perceptions of comparative harm to reflect descriptive norms, while we found clearer evidence explaining the use and non-use of e-cigarettes through parental and peer approval of vaping. However, these norms were fluid, diverse and sometimes contradictory. This review provides a resource for researchers, policymakers and practitioners to better understand the ways that emerging norms could be influenced through policy and practice.

Impact of tobacco and/or nicotine products on health and functioning: a scoping review and findings from the preparatory phase of the development of a new self-report measure

BACKGROUND

Measuring self-reported experience of health and functioning is important for understanding the changes in the health status of individuals switching from cigarettes to less harmful tobacco and/or nicotine products (TNP) or reduced-risk products (RRP) and for supporting tobacco harm reduction strategies.

METHODS

This paper presents insights from three research activities from the preparatory phase of the development of a new self-report health and functioning measure. A scoping literature review was conducted to identify the positive and negative impact of TNP use on health and functioning. Focus groups (n = 29) on risk perception and individual interviews (n = 40) on perceived dependence in people who use TNPs were reanalyzed in the context of health and functioning, and expert opinion was gathered from five key opinion leaders and five technical consultants.

RESULTS

Triangulating the findings of the review of 97 articles, qualitative input from people who use TNPs, and expert feedback helped generate a preliminary conceptual framework including health and functioning and conceptually-related domains impacted by TNP use. Domains related to the future health and functioning measurement model include physical health signs and symptoms, general physical appearance, functioning (physical, sexual, cognitive, emotional, and social), and general health perceptions.

CONCLUSIONS

This preliminary conceptual framework can inform future research on development and validation of new measures for assessment of overall health and functioning impact of TNPs from the consumers' perspective.

An investigation of factors encouraging and deterring EC use: a thematic analysis of accounts from UK adults

OBJECTIVE

This study aimed to explore E-cigarette (EC) accounts from a small sample of UK adults with varied smoking/EC experiences. This was to contribute to existing knowledge of adult perceptions and understand the factors that encourage or deter use to inform health messaging aimed at professionals, policy makers and the general public.

DESIGN

Twelve participants, five men and seven women aged 23-55 years (mean age 32.43) with mixed smoking/EC backgrounds took part in face-to-face interviews, analysed using semantic-level inductive thematic analysis.

RESULTS

The analysis identified three key themes. Social influence (1) relates to the understanding of the social representations of ECs. Representation and knowledge (2) captures the impact of varied EC related communication on perception. Aspects of addiction (3) conveys aspects of nicotine addiction and how this influences EC use.

CONCLUSION

ECs were generally perceived as more socially acceptable than cigarettes by non-smokers, although there were varying levels of acceptability depending on the type of EC device used. There was also unanimity concerning uncertainty surrounding the devices. Behavioural/sensory elements and personal enjoyment of ECs were consistent elements that encouraged or deterred use. Although non-smokers/vapers did not use the devices, they expressed similar apprehensions to those who did.

Views and preferences of people living with HIV about smoking, quitting and use of nicotine products

AIMS AND BACKGROUND

People living with HIV (PLHIV) have a higher rate of smoking and experience a greater burden of tobacco-related disease than the general population. This study aimed to understand the role smoking plays in the lives of PLHIV, participants' views of traditionally available nicotine products (e.g., nicotine replacement therapy or NRT) and novel nicotine products (e.g., nicotine vaping products or NVPs) as both short-term quit aids and long-term substitutes for cigarettes.

METHODS

Semi-structured focus groups were conducted with PLHIV who smoked. Focus groups were transcribed and analysed using a combination of deductive and inductive thematic analysis. A brief questionnaire of nicotine product use and interest was also completed and the quantitative data presented using descriptive statistics.

RESULTS

Fifty-four participants took part in 11 focus groups. Participants' views of smoking, quitting and nicotine products were diverse. Commitment to smoking and interest in quitting were categorised into three groups across a smoking-quitting continuum: committed to smoking, ambivalent about smoking and reluctantly smoking. NRT was criticised for a range of side effects and primarily considered as a short-term cessation aid. NVPs generated debate. NVPs that closely resembled cigarettes were viewed as the most acceptable product and were considered to be more suitable than NRT for long-term use.

DISCUSSION AND CONCLUSIONS

Understanding the unique needs, goals and views of PLHIV related to smoking, quitting smoking and using nicotine products could inform development of novel and tailored smoking interventions for PLHIV. NVPs should be further examined as potential long-term substitutes for PLHIV who are ambivalent about smoking. However, traditional smoking cessation assistance (approved cessation aids and counselling) is likely to be most appropriate for PLHIV who are reluctantly smoking.

An Evaluation of the Knowledge and Perceptions of Pharmacy Staff and Pre-Registration Students of E-Cigarettes Use: A Systematic Review

INTRODUCTION

Pharmacy staff are a trusted source of advice on the safe and appropriate use of medicines and devices. Retail pharmacies deliver smoking cessation services and sell e-cigarettes in the UK. This review asks 'what knowledge, experience and ability do staff have to support e-cigarette users to quit smoking'.

METHODS

A systematic literature search was undertaken drawn on predefined eligibility criteria and a comprehensive search strategy following the PRISMA guideline. Eligible papers reported survey-research published in English from 2015 to 2020. PubMed, Google Scholar, OVID, EMBASE and MEDLINE Databases were searched. No restrictions on study design or language were applied. Two reviewers independently screened for inclusion/exclusion and then extracted the relevant information from the articles for synthesis.

RESULTS

Of 12 potentially eligible full-text studies, 1 was a duplicate, 7 were excluded as per eligibility criteria. Four papers were finally included in this literature review. Two studies indicated that pharmacy staff are less confident in giving advice on e-cigarette use. Knowledge on the adverse effects of e-cigarettes compared to traditional smoking cessation aids remain unclear. In one study, 42% of community pharmacists did not believe that e-cigarettes could be used for smoking cessation. Three studies identified need for specific regulations and professional support. The overall certainty of the evidence is 'low' or 'very low', with moderate levels of bias.

CONCLUSION

Pharmacists may be well placed to implement e-cigarette smoking cessation interventions, but most practitioners lacked knowledge and ability to support these customers citing unclear risk of harm. Pharmacists felt secure in recommending traditional cessation tools. Further regulation, guidelines and training is needed. Findings may be less generalizable in countries where e-cigarettes are banned. Their extent of knowledge, experience and ability to support users of e-cigarettes within their community to quit smoking is lacking.

Intentions to Seek Information about E-Cigarettes: Perceived Risk, Efficacy, and Smoking Identity

While e-cigarette use increases in the US., people's knowledge about e-cigarettes is limited. Information seeking may influence people's knowledge about e-cigarettes. Using the risk perception attitude framework and the identity theory, this study examined if U.S. adult current smokers (n = 1,841) differing in perceived efficacy of switching completely to e-cigarettes, perceived risk of cigarette smoking, and smoking identity report different levels of intentions to seek information about e-cigarettes. Results revealed that smokers with high perceived risk of smoking and perceived efficacy about switching completely to e-cigarettes (responsive group) reported strongest intentions to seek information about e-cigarettes (M = 5.41 on a 1-7 scale), followed by the group having low smoking risk perceptions and high e-cigarette efficacy beliefs (proactive group; M = 4.58), the group having high smoking risk perceptions and low e-cigarette efficacy beliefs (avoidance group; M = 3.18), and the group low on both factors (indifference group; M = 2.76). The differences between responsive group and proactive, avoidance, and indifference groups were greater among smokers with high (M_diff = 6.14) vs. low (M_diff = 5.27) smoking identity. Theoretical and practical implications of the findings are discussed.

A qualitative study of e-cigarette use among young people in Ireland: Incentives, disincentives, and putative cessation

BACKGROUND

Smoking prevalence in Ireland is falling in all age groups, but e-cigarette use is rising among young people. This qualitative study explores young people's accounts of e-cigarette use in Ireland.

METHODS

Semi-structured individual (22) and focus group (8) interviews were conducted with 62 young people aged 18-22 years, recruited from a higher-education institution and youth organisations working with early school-leavers across Dublin. All were smokers or ex-smokers; 41 had tried e-cigarettes, 11 continued as dual users. We identified themes using thematic data analysis.

RESULTS

Three broad themes were identified: incentivising features, disincentivising features, and ambivalent and unsuccessful cessation, named putative smoking cessation. Incentivising features included price, pleasing taste/ flavours, and the possibility of indoor use. Disincentivising features related to adverse health effects (pain, discomfort, sore throat, coughing, headache) and unpleasant physical effects (bad taste, problems resulting from device faults). Other disincentives were over-consumption arising from inability to control intake, "greater addictiveness", product taste, and device faults. Putative cessation refers to the conflict between participants' expected use of e-cigarettes as a smoking cessation/reduction aid and their observed reality of e-cigarettes' failure in this regard, with reported outcomes including: failure to quit or reduce; continued or resumed cigarette and/or roll-your-own smoking; dual use of e-cigarettes and other tobacco products; and inability to quit e-cigarettes.

CONCLUSIONS

Participants were sceptical about e-cigarettes' "purported relative healthiness", concerned about addictiveness and potential long-term health consequences, and critically aware of advertising and industry strategies. E-cigarettes were viewed as being less denormalised, in part because they could be used in indoor spaces where smoking is banned in Ireland. Although price, taste, and perceived renormalisation were important motivators for young people's use of e-cigarettes, they wanted to quit smoking. The regulation of e-cigarettes through age restriction of access, licensing of outlets, pricing, point of sale and advertising restrictions as well as through the banning of indoor use should be considered by legislators and tobacco control policymakers.

Attitudes towards a hypothetical 'clean nicotine' product and harm reduction among smokers

BACKGROUND

Cleaner nicotine delivery devices, such as nicotine vaping products (NVPs), could expose smokers to less harm than combustible cigarettes. While use of NVPs is increasing, it is unknown how harm reduction attitudes are related to intention to use these or other "clean nicotine" products and how smokers would prefer to use them.

METHODS

A sample of 1,538 Australian smokers participated in an online survey. Questions covered use NVPs and nicotine replacement therapy (NRT), and attitudes towards a hypothetical "clean nicotine" product and tobacco harm reduction.

RESULTS

Lifetime use of NVPs was reported by 21% of participants, while 42% reported that they would probably or definitely use NVPs as a cessation aid in the future. Around three-quarters expressed interest in using a hypothetical clean nicotine product as a short-term cessation aid (75.7%), a long-term substitute for cigarettes (72.4%), or as a partial replacement for cigarettes (74.9%). However, despite this interest, 52% endorsed the statement that using nicotine products long-term was undesirable because it maintained nicotine addiction. A binary logistic regression showed that interest in using the hypothetical "clean nicotine" product was associated with higher education, moderate nicotine dependence, support of tobacco harm reduction, and previous use of NRT and NVPs.

CONCLUSION

Most smokers were interested in the use of a hypothetical clean nicotine product that is as addictive as combustible cigarettes but much less harmful. However, many of the participants who were interested in the use of a hypothetical clean nicotine product also endorsed statements that long-term addiction to nicotine is undesirable. These seemingly contradictory findings have implications for communication with smokers about tobacco harm reduction approaches with non-smoked nicotine products.

Motivations for use, identity and the vaper subculture: a qualitative study of the experiences of Western Australian vapers

BACKGROUND

Vaping is a relatively new practice, and therefore its symbolic meanings and social practices are yet to be fully understood, especially within Australia where the practice is strictly regulated. This study aimed to examine vapers motivations for use, reinforcing influences, and association with the vaper subculture.

METHODS

Working from a constructivist epistemology and a symbolic interaction framework, in-depth interviews were conducted with a purposive sample of 37 current (89%) and former (11%) adult vapers, 70% male, mean age of 32.5. Data was analysed via thematic analysis.

RESULTS

Vapers largely started vaping to quit smoking and underwent common experiences during their initiation phase. Subsequently, vapers tended to adopt one of two dominant identities, that of the 'cloud chaser' or the 'substitute', which some users moved between during different stages of their vaping career. The social and symbolic meaning of e-cigarettes and vaping varied and involved concepts of harm reduction, addiction, pleasure, stigma and community, and for some, connection to the vaper subculture.

CONCLUSIONS

Understanding the complexities of vaping, and the nuanced differences of 'cloud chasers' and 'substitute' vapers may have important implications for health communication, research and policy. E-cigarette users within this sample were not a homogeneous group and differed in their motivations for use, association with the vaper subculture and relationship with the vape community. These findings provide new insights into the socialisation process and subsequent identity adoption of vapers within the unique regulatory environment of Western Australia.

Electronic Cigarettes Prevalence and Awareness Among Jordanian Individuals

The general awareness regarding E-smoking is varying from country to other depending on multivariable factors. We try to investigate the prevalence of E-Cigarette Awareness, Perceived Harmfulness, Prevalence, and Associations with Smoking-Cessation Outcomes among different age groups and different sex in Jordanian individuals. The study element shaped by data gathered from various questionnaire surveys. The questionnaire was of our own design the method of data collection was through online surveys Different applications were used to distributing the questionnaire including; Whatsapp, Facebook, Instagram, other social applications. The study included 1536 participants. The prevalence of E-smoking is 18% among Jordanian individuals where it is 24.9% in males and 3.5% in females. 47.3% of participants believe that E-smoking has less harmful effects than traditional cigarette smoking while 46.7% believe that E-smoking has the same risk of cigarette smoking. 56% of participants believe the E-smoking can lead to addiction. E-smoking is considered an emerging modality of smoking with limited data regarding its long term impact regarding its addictive behavior and toxic effect. Awareness program regarding E-smoking is mandatory especially for the nontraditional smoker and young people.

Inequalities, harm reduction and non-combustible nicotine products: a meta-ethnography of qualitative evidence

BACKGROUND

We sought to review qualitative evidence on how smokers in different socioeconomic groups engage with non-combustible nicotine products (NCNP), including electronic cigarettes and nicotine replacement therapies, in order to provide insight into how these products might impact on smoking inequalities.

METHODS

We searched ten electronic databases in February 2017 using terms relating to NCNP and socioeconomic status. We included qualitative studies that were published since 1980 and were available in English. We used guidelines adapted from the Critical Appraisal Skills Programme for appraising qualitative research.

RESULTS

The review only identified studies exploring the attitudes of socioeconomically disadvantaged smokers towards NCNP for harm reduction or cessation purposes (i.e. we did not identify any relevant studies of more advantaged socioeconomic groups). Using a lines-of-argument meta-ethnographic approach, we identified a predominantly pessimistic attitude to NCNP for harm reduction or cessation of smoking due to: wider circumstances of socioeconomic disadvantage; lack of a perceived advantage of alternative products over smoking; and a perceived lack of information about relative harms of NCNP compared to smoking. Optimistic findings, although fewer, suggested the potential of NCNP being taken up among smokers experiencing socioeconomic disadvantage.

CONCLUSIONS

Overall, our review highlights the importance of considering the social, cultural and economic circumstances that influence experiences of smoking and of alternative product use.

Motivations for using electronic cigarettes in young adults: A systematic review

Background: The most common reasons why adults use e-cigarettes are to stop or reduce tobacco smoking. However, it is unclear if this reason is evenly distributed between young and older adults. Objectives: describe the motivations for e-cigarette use amongst young adults aged 18-25 and compare the reasons for using e-cigarettes of people who currently or formerly used tobacco products to those who had never smoked tobacco prior e-cigarette use. Methods: PubMed^®, Scopus^®, Cochrane Library^®, SocINDEX^®, PsycARTICLES^®, Psychology and Behavioral Sciences Collection^® and PsycINFO^® databases were used. English written articles were screened up to March 2018. Depending on study design, quality was assessed using The STROBE or RATS checklists. Results: Six articles were included in the review, all with a moderate quality of evidence. Independently of smoking status, curiosity was the most frequently reported reason for initiating the use of e-cigarettes in young adults. Reasons for continuing to use e-cigarettes were various. The continued use of e-cigarettes could be either a means to replicate smoking habits, or a way for a different and personalized use of nicotine by inhalation. Conclusions: Reasons for using e-cigarettes in young adults are varied and are not limited to stopping smoking.

Nicotine addiction as a moral problem: Barriers to e-cigarette use for smoking cessation in two working-class areas in Northern England

Tobacco use in high-income countries correlates with socio-economic disadvantage, but although switching to electronic cigarettes could be a safer alternative, little is known about barriers to use. Drawing on eighteen months of data collection in two areas of Northern England in 2017/18 including ethnography and interviews with 59 smokers and e-cigarette users, I show that concern about continued nicotine addiction either deterred working-class smokers from switching to e-cigarettes or dictated the conditions of their use. Research participants were unhappy about addiction both as loss of control experienced as moral failure and as neglect of financial responsibilities i.e. role performance failure in relation to family responsibilities, or what I call ‘thrift as care’. They reduced the moral burden of addiction by lowering nicotine content, rejecting pleasure and minimising expenditure. They chose the cheapest possible tobacco, switched from combusted tobacco to cheaper e-cigarettes and bought cheap e-cigarettes and liquids. For working-class smokers, minimising spend on what they perceive negatively as addiction may be a greater moral concern than reducing health risk. I conclude that ensuring that vaping is significantly cheaper than smoking may be key to addressing health inequalities linked to tobacco use.

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Working-class smokers avoided e-cigarettes because of concern about addiction.

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Those who did switch preferred a medical to a recreational model of use.

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Users reduced nicotine content, minimised spending and avoided exotic flavours.

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Failure of willpower and role performance (thrift as care) created addiction shame.

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Ensuring that vaping is cheaper than smoking is key to harm reduction.

"Cloud chasers" and "substitutes": e-cigarettes, vaping subcultures and vaper identities

The use of e-cigarettes is increasing, a practice denoted as vaping. We explore user motives, self-identity as vapers and involvement in vaping subcultures, drawing on sociological theory of stigma, subcultures and symbolic boundaries. Based on analyses of semi-structured interviews with 30 Norwegian vapers, we find that there is a vaping subculture in Norway. We identify two dominant vaper identities. The first is labelled cloud chasers. These were dedicated vapers who identified with symbols and values in the subculture. Many were politically engaged in improving vaping regulation regimes and felt a sense of belonging to a vaping community. The second group is labelled substitutes. These were former daily smokers who used e-cigarettes for smoking cessation in a more pragmatic and defensive manner, to avoid health risks, to escape the stigma of smoking and to manage nicotine addiction. In this group, self-identity as a vaper was generally lacking. Vaping was often symbolically linked to the stigmatised smoker identity they wanted to escape, and was restricted to private contexts. The perceived symbolic meaning of e-cigarettes varies: for some, they are a symbol of pleasure and community. For others, they connote the stigmatised status of the addicted smoker seeking an alternative to cigarettes.

An Interpretative Phenomenological Analysis of Discontinued Use of the E-Cigarette

Introduction: Many UK smokers use e-cigarettes as a quitting aid; however, a substantial number discontinue use of the e-cigarette and revert to smoking. Understanding why this may happen is important both for individuals and for stop smoking services.

Aims: To explore young adult smokers’ experiences of use and discontinued use of the e-cigarette.

Methods: Semi-structured interviews were conducted with six participants who tried e-cigarettes for at least seven days and returned to smoking. Data was transcribed and analysed using interpretative phenomenological analysis.

Results: Findings suggested participants held conflicting attitudes about using e-cigarettes, which undermined attempts to quit smoking, and led to the discontinuation of the e-cigarette. These conflicts centred on participants’ discomfort with the e-cigarette or vaping identity, lack of abstinence self-efficacy and navigation of barriers to e-cigarette use. The complex interplay of these factors may have led to an underestimation of the individual effort required to continue vaping and reinforced participants’ perception of the e-cigarette as an inferior product to the cigarette.

Conclusions: Future research should focus on the role of identity, self-efficacy, control and smokers’ expectations of e-cigarettes on smoking cessation as these may be important factors to consider for a more tailored service for e-cigarette users.

Experiences of women with cervical dysplasia and associated diagnoses using electronic cigarettes for smoking substitution

Introduction

The aim of this qualitative study was to describe the motivation and experiences of women with cervical dysplasia and associated diagnoses who used electronic cigarettes (ECs) to reduce the number of cigarettes they smoked.

Methods

Qualitative interviews were conducted with 26 women aged 18‐65 years with cervical dysplasia and associated diagnoses who smoked at least three cigarettes daily for the past year or more and who enrolled in an intervention designed to substitute regular cigarettes with ECs. At the 12‐week follow‐up, patients were contacted by telephone. Semi‐structured interviews were recorded, then transcribed, coded and analysed for themes.

Results

When confronted with a new diagnosis associated with smoking, women in this study were eager to try ECs to help them reduce their intake of cigarettes. Women reported that physical cues similar to smoking, delivery of nicotine sufficient to assist with smoking reduction and the security of having the device available to use in instances where temptations to smoke may occur were all positive experiences in trying the device. Other women in the study reported negative experiences, such as a lack of sufficient nicotine to eliminate cravings, heaviness of the device and the need to keep it charged. Depression, nicotine addiction and habit were factors that made it difficult to decrease cigarette consumption.

Conclusions

Findings suggest that ECs may help with smoking substitution in patients who must reduce smoking due to medical conditions or diagnoses.

Barriers and facilitators to switching from smoking to vaping: Advice from vapers

INTRODUCTION AND AIMS

Information available to consumers about nicotine vaping products varies according to the regulatory environment. A common information source in Australia, where nicotine vaping products are highly regulated, is advice from vapers. The aim of this study was to report on what advice current vapers would give to someone new to vaping.

DESIGN AND METHODS

Australian vapers were recruited in 2016 via the International Tobacco Control Four-Country Smoking and Vaping survey of smokers and ex-smokers, as well as a separate recruitment process that targeted vapers. A total of 384 of 559 eligible participants responded to an open-ended question about barriers to switching from smoking to vaping, and what advice they would give to new vapers.

RESULTS

While some participants reported switching from smoking to vaping easily, others described an adjustment period. Difficulties included learning about technical aspects of nicotine vaping products, finding the 'right' combination of device and liquid, and accessing nicotine liquid given that it cannot legally be sold. Many accounts of satisfaction with quitting smoking and improved health were provided.

DISCUSSION AND CONCLUSIONS

Advice from current vapers is likely to be particularly influential in Australia, where information about vaping is not easily available from health organisations or official government sources. This research shows that advice to new vaper centres around experimentation with devices and flavours and finding trustworthy suppliers of nicotine liquid. It provides an insight into the initial challenges associated with switching from smoking to nicotine vaping products in environments where access to nicotine liquid is highly restricted.

Electronic cigarettes: a task force report from the European Respiratory Society

There is a marked increase in the development and use of electronic nicotine delivery systems or electronic cigarettes (ECIGs). This statement covers electronic cigarettes (ECIGs), defined as "electrical devices that generate an aerosol from a liquid" and thus excludes devices that contain tobacco. Database searches identified published articles that were used to summarise the current knowledge on the epidemiology of ECIG use; their ingredients and accompanied health effects; second-hand exposure; use of ECIGs for smoking cessation; behavioural aspects of ECIGs and social impact; in vitro and animal studies; and user perspectives.ECIG aerosol contains potentially toxic chemicals. As compared to conventional cigarettes, these are fewer and generally in lower concentrations. Second-hand exposures to ECIG chemicals may represent a potential risk, especially to vulnerable populations. There is not enough scientific evidence to support ECIGs as an aid to smoking cessation due to a lack of controlled trials, including those that compare ECIGs with licenced stop-smoking treatments. So far, there are conflicting data that use of ECIGs results in a renormalisation of smoking behaviour or for the gateway hypothesis. Experiments in cell cultures and animal studies show that ECIGs can have multiple negative effects. The long-term effects of ECIG use are unknown, and there is therefore no evidence that ECIGs are safer than tobacco in the long term. Based on current knowledge, negative health effects cannot be ruled out.

"They're thinking, well it's not as bad, I probably won't get addicted to that. But it's still got the nicotine in it, so…": Maturity, Control, and Socializing: Negotiating Identities in Relation to Smoking and Vaping-A Qualitative Study of Young Adults in Scotland

Objective

To explore the understandings of and engagement with e-cigarettes, of young adults from disadvantaged backgrounds, and how these may have an impact on existing smoking identities.

Methods

Twenty-two small group and 11 individual qualitative interviews were conducted in Central Scotland with 72 16-24 year olds between September 2015 and April 2016. Participants were mostly smokers and ex-smokers from socioeconomically disadvantaged backgrounds.

Results

Although most participants had tried e-cigarettes, they generally held ambivalent views about e-cigarettes and vaping. Two overarching themes were identified which helped in understanding this. Firstly, e-cigarettes were understood by the participants in relation to their existing smoking identities. Vaping was viewed as less controllable and more addictive than smoking, which did not fit with their self-identity as controlled smokers. Secondly, they felt that vaping could not replace the social and cultural importance that smoking had in their lives.

Conclusion

This study suggests that though young adults from disadvantaged areas are trying e-cigarettes for various reasons, vaping is rarely sustained. Through their own experiences of vaping and their observations of others vaping, the participants perceive the behavior as endangering an existing acceptable and controlled smoking identity. Additionally, e-cigarettes were considered to be a jarring presence in existing social situations where smoking was valued. This study, therefore, provides insights into how young adults may be rationalizing their continued smoking in the face of potentially less harmful alternatives.

Implications

As new and novel nicotine delivery devices, and due to their similarity to smoking, e-cigarettes have the potential to help smokers in their quit attempts. However, the findings from this study raise questions about whether e-cigarettes are regarded as having this potential by young adult smokers from disadvantaged socioeconomic environments where smoking is more commonplace and acceptable.

GPs' and nurses' perceptions of electronic cigarettes in England: a qualitative interview study

BACKGROUND

Reports from royal colleges and organisations such as Public Health England suggest that GPs and nurses should advise patients to switch to electronic cigarettes (e-cigarettes) if they do not want to stop smoking using licensed medication. However, there are no data on what practitioners think, feel, or do about e-cigarettes.

AIM

To explore practitioners' perceptions and attitudes towards e-cigarettes, and their experiences of discussing e-cigarettes with patients.

DESIGN AND SETTING

A qualitative interview study was carried out with semi-structured interviews conducted with nurses and GPs across England in 2017.

METHOD

Participants were interviewed once either via telephone or face to face. Data were analysed using thematic analysis.

RESULTS

Interviews were conducted with 23 practitioners (eight nurses and 15 GPs). There were three key themes: ambivalence and uncertainty; pragmatism; and responsibility. Many practitioners had uncertainties about the safety and long-term risks of e-cigarettes. Some had ambivalence about their own knowledge and ability to advise on their use, as well as uncertainty about whether to and what to advise patients. Despite this, many sought to provide honesty in consultations by acknowledging these uncertainties about e-cigarettes with patients and taking a pragmatic approach, believing that e-cigarettes were a 'step in the right direction'. Practitioners wanted advice from healthcare regulators such as the National Institute for Health and Care Excellence to reassure them about the safety of e-cigarettes, practical tools to support the consultation, and to control their use by providing behavioural support programmes for reduction or cessation.

CONCLUSION

Current dissemination strategies for guidelines are not effective in reaching practitioners, who are offering more cautious advice about e-cigarettes than guidelines suggest is reasonable.

Tobacco and electronic cigarette products: awareness, cessation attitudes, and behaviours among general practitioners

BACKGROUND

Little is known around how general practitioners (GP) approach tobacco products beyond traditional cigarettes.AimTo examine GP perceptions of tobacco and electronic cigarette (EC) products, and their attitudes and behaviours towards product cessation.

METHOD

A 13-item self-completed anonymous questionnaire measured awareness of waterpipe tobacco smoking (WTS) and smokeless tobacco (ST). Cessation advice provision, referral to cessation services, and the harm perception of these products were asked using five-point Likert scales that were dichotomised on analysis. Correlates of cessation advice were analysed using regression models.FindingsWe analysed 312 responses, of whom 63% were aware of WTS and between 5-32% were aware of ST products. WTS and ST were considered less harmful than cigarettes by 82 and 68% of GPs, respectively. WTS, ST, and EC users were less advised (P<0.001) and referred (P<0.001) to cessation services compared to cigarette users. Ethnic minority and senior GPs were more likely to provide cessation advice for WTS and ST users compared to younger white GPs. GPs who were recent tobacco users were less likely to give cessation advice to cigarette users (adjusted odds ratios 0.17, 95% confidence interval 0.03-0.99, P<0.049).Conclusions (implications for practice and research)GPs had lower harm perception, gave less cessation advice, and made less referrals for WTS and ST users compared to cigarettes. Our findings highlight the need for targeted tobacco education in general practice. More research is needed to explore GP perceptions in depth as well as patient perspectives.

Smokers' Understandings of Addiction to Nicotine and Tobacco: A Systematic Review and Interpretive Synthesis of Quantitative and Qualitative Research

Background

Despite the centrality of addiction in academic accounts of smoking, there is little research on smokers' beliefs about addiction to smoking, and the role of nicotine in tobacco dependence. Smokers' perspectives on nicotine's role in addiction are important given the increasing prevalence of nontobacco nicotine products such as e-cigarettes. We conducted a systematic review of studies investigating smokers' understandings and lay beliefs about addiction to smoking and nicotine.

Method

We searched PubMed, Embase, CINAHL, and PsycINFO for studies investigating lay beliefs about addiction to smoking. Twenty-two quantitative and 24 qualitative studies met inclusion criteria. Critical interpretive synthesis was used to analyze the results.

Results

Very few studies asked about addiction to nicotine. Quantitative studies that asked about addiction to smoking showed that most smokers believe that cigarettes are an addictive product, and that they are addicted to smoking. Across qualitative studies, nicotine was not often mentioned by participants. Addiction to smoking was most often characterized as a feeling of "need" for cigarettes resulting from an interplay between physical, mental, and social processes. Overall, we found that understandings of smoking were more consistent with the biopsychosocial model of addiction than with more recent models that emphasize the biological aspects of addiction.

Conclusion

Researchers should not treat perceptions of addiction to smoking interchangeably with perceptions of addiction to nicotine. More research on lay beliefs about nicotine is required, particularly considering the increasing use of e-cigarettes and their potential for long-term nicotine maintenance for harm reduction.

Implications

Quantitative studies show that most smokers believe that smoking is addictive and that they are addicted. A feeling of "need" for cigarettes was central to qualitative accounts of addiction, but nicotine was not often discussed. Overall, smokers' understandings of addiction reflect a biopsychosocial model rather than a neurobiological one. Given the growing market for e-cigarettes and therapeutic nicotine, more research is required on lay beliefs about nicotine and addiction.

Developing E-cigarette friendly smoking cessation services in England: staff perspectives

BACKGROUND

Public health leadership in England has taken a distinctive international stance by identifying the potential public health benefit of e-cigarettes for smoking cessation. This includes the development of a ground-breaking set of national guidelines for developing e-cigarette friendly stop smoking services. However, little is known about the views of staff engaged within these services and whether or how such services are becoming e-cigarette friendly. This study aimed to investigate the uptake and usage of e-cigarette guidance, from the perspective of those enacting tobacco cessation interventions 'on the ground'.

METHODS

Qualitative semi-structured interviews were conducted with 25 cessation service staff, including advisors (n = 15), managers (n = 5) and commissioners (n = 5) from eight different services in the South-West of England, UK. A thematic analysis of the transcripts was conducted using NVivo software.

RESULTS

Although some stop smoking services labelled themselves e-cigarette friendly, there was no consensus over what this should entail. For some, this meant active engagement, such as working with local vape shops, and in the case of one service, offering e-cigarettes through a voucher scheme to disadvantaged groups. For others, an e-cigarette friendly service was conceptualized in a passive sense, as one which welcomed service users using e-cigarettes. Many services did not use the 'e-cigarette friendly' claim in their branding or promotional material. Several discursive themes underlay differing staff attitudes. Those more reluctant to engage framed this in terms of their 'duty of care', with concerns focusing on the addictiveness of nicotine, lack of medically licensed product and ongoing scientific controversy. Those motivated to engage drew on a discourse of social justice goals and 'doing things differently' in relation to lower socio-economic status smokers, those with mental health issues and other vulnerable groups. Strong public health leadership was also identified as a key factor in changing staff attitudes towards e-cigarettes.

CONCLUSIONS

On-the-ground enactment of e-cigarette friendly services is varied as well as reflective of the wider policy and regulatory environment. Although the context of English stop smoking services is one of austerity and change, there are opportunities for active engagement with e-cigarettes to achieve overall cessation goals. For this to occur, training, policy consistency and sharing best practice are needed.

Electronic nicotine devices to aid smoking cessation by alcohol- and drug-dependent clients: protocol for a pilot randomised controlled trial

Background

Up to 95% of people entering treatment for use of alcohol or other drugs (AOD) smoke tobacco. Smokers receiving treatment for AOD use are interested in quitting and make quit attempts, but relapse is more common and rapid compared with the general population of smokers. New ways to address smoking in this population are needed. Electronic nicotine devices (ENDs) or electronic cigarettes hold significant potential as both cessation aids and harm reduction support. This study focuses on the potential of ENDs to facilitate smoking cessation and to sustain it in the medium term among people in treatment for AOD use. The aim of this trial is to explore the effectiveness, feasibility and acceptability of ENDs for smoking cessation compared with combination nicotine replacement therapy (NRT) for clients after discharge from a smoke-free AOD residential withdrawal service.

Methods/design

The study is a pragmatic randomised controlled trial. In total, 100 participants will be recruited following admission to a smoke-free residential withdrawal service in Melbourne, Australia. Participants will complete a baseline survey and be randomised to either the END group (n = 50) or the NRT group (n = 50) prior to discharge. Both groups will receive telephone counselling support from quitline. Follow-up measures will be assessed at 6 and 12 weeks following discharge. The primary outcome is continuous abstinence from smoking at 12 weeks post discharge. Secondary outcomes include: 7-day point prevalence from smoking, point prevalence abstinence from all nicotine (including NRT and ENDs), cravings and withdrawal, time to relapse, and treatment adherence (use of NRT, ENDs and quitline).

Discussion

This is the first randomised controlled trial to assess the effectiveness and acceptability of ENDs within a population dependent on AOD, a priority group with very high levels of smoking. The research will test a model of how to incorporate novel smoking cessation support into a period of high treatment receptiveness.

Trial registration

Australian New Zealand Clinical Trial Registry, ACTRN12617000849392. Registered on 8 June 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2786-1) contains supplementary material, which is available to authorized users.

Smokers' knowledge and perception of electronic cigarettes (e-cigarettes): a qualitative study of non-quitting smokers in a North London general practice

BACKGROUND

The introduction of electronic cigarettes (e-cigarettes) has provided smokers with an alternative source of nicotine. Interest and use of the device has increased exponentially in the last decade with an estimated 2.9 m adult users in Great Britain. Research so far on the attitudes and perceptions of smokers to this new product has largely focussed on the views of current e-cigarette users, smokers attempting to quit and former cigarette smokers.

AIM

This study aimed to explore the views of current tobacco smokers who were not using e-cigarettes and not looking for a cessation method, their understanding and knowledge of e-cigarettes, and their views of e-cigarettes as a smoking cessation aid provided by the National Health Service (NHS).

METHODS

Semi-structured in-depth interviews were conducted with 14 patients from a general practice in North London, who smoked conventional tobacco cigarettes on a daily or weekly basis, over 18 years old. An iterative approach allowed for constant data analysis using a thematic approach throughout the data collection stage, and generated four recurring themes.

FINDINGS

E-cigarettes were primarily seen as a smoking cessation device, with the supply of nicotine viewed as a benefit helping to reduce withdrawal symptoms, although for some participants this supply could also be a hindrance to dealing with their addiction. Despite uncertainty about the components, e-cigarettes were mostly viewed as healthier due to their lack of carcinogens, tar and smoke inhalation. The lack of reliable information and strong evidence for both the effectiveness and the safety of e-cigarettes led participants to be apprehensive about their provision by the NHS, and acted as a barrier to their use as an aid to quitting. The recurring appeal for more information regarding e-cigarettes make it clear that further high-quality research is urgently needed in this field to provide reliable and accurate information to smokers.

E-cigarettes, vaping and performativity in the context of tobacco denormalisation

E-cigarettes are devices through which a nicotine solution is 'vapourised' and inhaled by the user. Unlike cigarettes, the process involves no tobacco combustion. However, the inhalation and exhalation of vapour is reminiscent of smoking and there is debate about the possible harms and benefits of e-cigarette use, including the 'renormalisation' of smoking. Despite these debates, there has been little exploration into the embodied and semiotic similarities between smoking and vaping. This paper views the practices of vaping and smoking through the lens of performativity that is, the accumulation of meaning associated with the habits over time and space. Through in-depth interviews, we explore how young adults from primarily disadvantaged areas in Scotland, understand the similarity in practices between smoking and vaping. Participants talked about financial barriers to using different types of e-cigarettes, and how their use reflected their views on smoking cessation. They also discussed the embodied similarities between smoking and vaping, with divergent opinions on whether this continuance of habit was beneficial or not, revealing still developing and ambiguous norms around performativity. The norms of vaping were also frequently discussed, with participants' experiences and views reflecting the contested position of vaping in an environment where cigarette smoking is denormalised.

Views on and experiences of electronic cigarettes: a qualitative study of women who are pregnant or have recently given birth

BACKGROUND

Electronic cigarettes (ECs) are increasingly used for reducing or stopping smoking, with some studies showing positive outcomes. However, little is known about views on ECs during pregnancy or postpartum and previous studies have nearly all been conducted in the US and have methodological limitations, such as not distinguishing between smokers and ex/non-smokers. A greater understanding of this topic will help to inform both clinicians and EC interventions. We elicited views and experiences of ECs among UK pregnant or recently pregnant women.

METHODS

We conducted semi-structured telephone interviews, using topic guides, with pregnant or recently pregnant women, who were current or recent ex-smokers. To ensure broad views of ECs were obtained, recruitment was from several geographical locations and via various avenues of recruitment. This included stop smoking services, antenatal and health visitor clinics, a pregnancy website and an informal network. Participants were 15 pregnant and 15 postpartum women, including nine current EC users, 11 ex-users, and 10 never-users. Five women who were interviewed in pregnancy were later interviewed in postpartum to explore if their views had changed. Audio data was transcribed verbatim and framework analysis was applied.

RESULTS

Five main themes emerged: motivations for use (e.g., for stopping or reducing smoking), social stigma (e.g., avoiding use in public, preferring 'discrete' NRT), using the EC (e.g., mostly used at home); consumer aspects (e.g., limited advice available), and harm perceptions (e.g., viewed as less harmful than smoking; concerns about safety and addiction).

CONCLUSIONS

ECs were viewed positively by some pregnant and postpartum women and seen as less harmful than smoking and useful as aids for reducing and stopping smoking. However, due to perceived social stigma, some women feel uncomfortable using ECs in public, especially during pregnancy, and had concerns about safety and nicotine dependence. Health professionals and designers of EC interventions need to provide women with up-to-date and consistent information and advice about safety and dependence, as well as considering the influence of social stigma.

How will e-cigarettes affect health inequalities? Applying Bourdieu to smoking and cessation

This paper uses the work of Bourdieu to theorise smoking and cessation through a class lens, showing that the struggle for distinction created the social gradient in smoking, with smoking stigma operating as a proxy for class stigma. This led to increased policy focus on the health of bystanders and children and later also to concerns about electronic cigarettes. Bourdieu's concept of habitus is deployed to argue that the e-cigarette helps middle-class smokers resolve smoking as a symptom of cleft habitus associated with social mobility or particular subcultures. E-cigarette use is also compatible with family responsibility and sociable hedonism; aspects of working-class habitus which map to the 'practical family quitter' and the 'recreational user' respectively. The effectiveness of class stigma in changing health behaviours is contested, as is the usefulness of youth as a category of analysis and hence the relevance of concerns about young people's e-cigarette use outside a class framework of smoking and cessation. With regard to health inequalities, whilst middle-class smokers have in class disgust a stronger incentive to quit than working-class smokers, there is potential for tobacco control to tap into a working-class ethos of family care and responsibility.

Knowledge, attitudes and beliefs towards e-cigarettes among e-cigarette users and stop smoking advisors in South East England: a qualitative study

Aim To explore how e-cigarettes are perceived by a group of e-cigarette users and a group of Stop Smoking Advisors (SSAs), what are the risks and benefits they associate with e-cigarettes and how do these understandings shape participants' attitude towards e-cigarettes?

METHOD

Face-to-face and phone interviews were conducted with 15 e-cigarette users and 13 SSAs in South East England between 2014 and 2015. Transcribed data were analysed inductively through thematic analysis. Findings E-cigarettes were used as a therapeutic aid to stop or cut down smoking and as a smoking substitute. A prominent theme is the uncertainty e-cigarettes have generated. This included ambiguity of e-cigarettes' status and efficacy, and ambiguity of e-cigarettes' physical and social risks. Different attitudes towards e-cigarettes were identified.

CONCLUSION

E-cigarettes' benefits and risks should be continuously evaluated, put into perspective and circulated to avoid ambiguity. Stop smoking services need to recognise the benefits that can be gained by using e-cigarettes as a harm reduction tool.

Dual use of electronic nicotine delivery systems (ENDS) and smoked tobacco: a qualitative analysis

INTRODUCTION

Electronic nicotine delivery systems (ENDS) arguably pose fewer health risks than smoking, yet many smokers adopt ENDS without fully relinquishing smoking. Known as 'dual use', this practice is widespread and compromises the health benefits that ENDS may offer. To date, few studies have explored how dual use practices arise and manifest.

METHODS

We conducted in-depth, semi-structured interviews with 20 current ENDS users from New Zealand who reported smoking tobacco at least once a month. We explored participants' smoking history, their recent and current smoking, trial, uptake and patterns of ENDS use, and future smoking and vaping intentions. We managed the data using NVivo V.11 and used a thematic analysis approach to interpret the transcripts.

RESULTS

Dual use practices among participants evolved in four ways. First, as an attempt to manage the 'inauthenticity' of vaping relative to smoking and to retain meaningful rituals. Second, as complex rationalisations that framed decreased tobacco use, rather than smoking cessation, as 'success'. Third, as a means of alleviating the financial burden smoking imposed and to circumvent smoke-free policies. Lastly, dual use reflected attempts to comply with social group norms and manage stigma.

CONCLUSIONS

Dual use reflects both social and physical cues. It assisted participants to navigate smoking restrictions and allowed them to manage divergent norms. Policies that discourage smoking, particularly excise tax increases on smoked tobacco and smoke-free space restrictions, appear important in prompting ENDS use. Future research could explore whether these policies also help foster complete transition from smoking to exclusive ENDS use.

Australian mental health care practitioners' practices and attitudes for encouraging smoking cessation and tobacco harm reduction in smokers with severe mental illness

Reducing the burden of physical illness among people living with severe mental illnesses (SMI) is a key priority. Smoking is strongly associated with SMIs resulting in excessive smoking related morbidity and mortality in smokers with SMI. Smoking cessation advice and assistance from mental health practitioners would assist with reducing smoking and smoking-related harms in this group. This study examined the attitudes and practices of Australian mental health practitioners towards smoking cessation and tobacco harm reduction for smokers with SMI, including adherence to the 5As (ask, assess, advise, assist and arrange follow up) of smoking cessation. We surveyed 267 Australian mental health practitioners using a cross-sectional, online survey. Most practitioners (77.5%) asked their clients about smoking and provided health education (66.7%) but fewer provided direct assistance (31.1-39.7%). Most believed that tobacco harm reduction strategies are effective for reducing smoking related risks (88.4%) and that abstinence from all nicotine should not be the only goal discussed with smokers with SMI (77.9%). Many respondents were unsure about the safety (56.9%) and efficacy (39.3%) of e-cigarettes. Practitioners trained in smoking cessation were more likely (OR: 2.9, CI: 1.5-5.9) to help their clients to stop smoking. Community mental health practitioners (OR: 0.3, CI: 0.1-0.9) and practitioners who were current smokers (OR: 0.3, CI: 0.1-0.9) were less likely to adhere to the 5As of smoking cessation intervention. The results of this study emphasize the importance and need for providing smoking cessation training to mental health practitioners especially community mental health practitioners.

A typology of vaping: Identifying differing beliefs, motivations for use, identity and political interest amongst e-cigarette users

BACKGROUND

The aim of this study was to identify and differentiate socially shared accounts of e-cigarette use (vaping) using Q-methodology, combining factor analysis with qualitative comments.

METHODS

Seventy statements on e-cigarettes, drawn from media, academic and online discussions, were sorted by participants along a continuum of agreement/disagreement, commenting on strongly ranked items. Each participant thus created their own 'account' of their vaping. A by-person correlation matrix of the sorts was conducted, then factor analysed, to identify similar accounts (p<0.01). Fifty-five UK vapers participated by post, 55% male, mean age of 46, 84% only vaping/16% vaping and smoking, 95% vaping daily.

RESULTS

Three accounts of e-cigarettes were identified. The first two were associated with having quit smoking; the third with ongoing tobacco smoking and vaping. In Factor One, 'Vaping as Pleasure', vaping was characterized as enjoyable, with long-term use envisaged and a medical model of vaping rejected. Factor One participants also held a strong vaping identity and were politically motivated to maintain the rights of adults to vape. In Factor Two, 'Vaping as Medical Treatment', vaping was understood as a pragmatic choice about how to medicate one's smoking addiction, with the aim being to treat and ultimately reduce nicotine dependence. In Factor Three, 'Ambivalent E-Cigarette Use', participants reported fewer benefits and harboured more negative beliefs about e-cigarettes; they also strongly rejected a vaper identity, having no interest in online forums or being labelled a 'vaper' themselves.

CONCLUSION

The UK e-cigarette users in this sample were not a homogeneous group; differing in their beliefs, motivations for use, identity and political interest. In particular they diverged on whether they accepted a medicalized account of vaping and identified as a vaper. Public health messages targeted to one group of e-cigarette users may not resonate with others.

Consumers' Preferences for Electronic Nicotine Delivery System Product Features: A Structured Content Analysis

To inform potential governmental regulations, we aimed to develop a list of electronic nicotine delivery system (ENDS) product features important to U.S. consumers by age and gender. We employed qualitative data methods. Participants were eligible if they had used an ENDS at least once. Groups were selected by age and gender (young adult group aged 18-25, n = 11; middle-age group aged 26-64, n = 9; and women's group aged 26-64, n = 9). We conducted five individual older adult interviews (aged 68-80). Participants discussed important ENDS features. We conducted a structured content analysis of the group and interview responses. Of 34 participants, 68% were white and 56% were female. Participants mentioned 12 important ENDS features, including: (1) user experience; (2) social acceptability; (3) cost; (4) health risks/benefits; (5) ease of use; (6) flavors; (7) smoking cessation aid; (8) nicotine content; (9) modifiability; (10) ENDS regulation; (11) bridge between tobacco cigarettes; (12) collectability. The most frequently mentioned ENDS feature was modifiability for young adults, user experience for middle-age and older adults, and flavor for the women's group. This study identified multiple features important to ENDS consumers. Groups differed in how they viewed various features by age and gender. These results can inform ongoing regulatory efforts.

Qualitative analysis of young adult ENDS users' expectations and experiences

OBJECTIVES

Despite extensive research into the determinants of electronic nicotine delivery system (ENDS) uptake, few studies have examined the psychosocial benefits ENDS users seek and experience. Using a consumer ritual framework, we explored how ENDS users recreated or replaced smoking practices, and considered implications for smoking cessation.

DESIGN

In-depth interviews; data analysed using thematic analysis.

SETTING

Dunedin, New Zealand.

PARTICIPANTS

16 young adult ENDS users (age M=21.4, SD=1.9; 44% female).

RESULTS

Participants reported using different ENDS to achieve varying outcomes. Some used 'cigalikes' to recreate a physically and visually similar experience to smoking; they privileged device appearance over nicotine delivery. In contrast, others used personally crafted mods to develop new rituals that differentiated them from smokers and showcased their technical expertise. Irrespective of the device they used, several former smokers and dual users of cigarettes and ENDS experienced strong nostalgia for smoking attributes, particularly the elemental appeal of fire and the finiteness of a cigarette. Non-smoking participants used ENDS to maintain social connections with their peers.

CONCLUSIONS

Participants used ENDS to construct rituals that recreated or replaced smoking attributes, and that varied in the emphasis given to device appearance, nicotine delivery, and social performance. Identifying how ENDS users create new rituals and the components they privilege within these could help promote full transition from smoking to ENDS and identify those at greatest risk of dual use or relapse to cigarette smoking.

Using e-cigarettes in the home to reduce smoking and secondhand smoke: disadvantaged parents' accounts

Electronic cigarettes (e-cigarettes) are subject to considerable public health debate. Most public health experts agree that for smokers who find it particularly challenging to quit, e-cigarettes may reduce harm. E-cigarette use in the home may also reduce children's secondhand smoke (SHS) exposure, although e-cigarette vapour may pose risks. This is the first qualitative study to explore disadvantaged parents' views and experiences of e-cigarettes in relation to reducing SHS exposure in the home. Interviews with 25 disadvantaged parents from Edinburgh who smoked and had children aged 1-3 were conducted in 2013, with 17 re-interviewed in 2014. Accounts of e-cigarette perceptions and use were analysed thematically. E-cigarettes were seen by some as potentially valuable in helping quitting or reducing smoking in difficult circumstances, and protecting children from SHS when smoking outside is constrained. However, parents raised concerns about safety issues and continuing their nicotine addiction. In relation to children, concerns included possible health effects of the vapour, children playing with them and role-modelling e-cigarette use. While significant concerns remain about e-cigarettes, for some parents who find it challenging to quit or safely leave their children to smoke outside, e-cigarettes may offer potential for reducing the harm to them and their children.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

Medicalisation, smoking and e-cigarettes: evidence and implications

There is debate in the tobacco control literature about the value of a medical model in reducing smoking-related harm. The variety of medical treatments for smoking cessation has increased, health professionals are encouraged to use them to assist smoking cessation and tobacco dependence is being described as a 'chronic disease'. Some critics suggest that the medicalisation of smoking undermines the tobacco industry's responsibility for the harms of smoking. Others worry that it will lead smokers to deny personal responsibility for cessation, create beliefs in 'magic bullets' for smoking cessation, or erode smokers' confidence in their ability to quit. We argue that the medicalisation of smoking will have limited impact due to the emphasis on population-based interventions in tobacco control, the ambiguous place of nicotine among other drugs and the modest efficacy of current pharmacotherapies. These factors, as well as lay understandings of smoking that emphasise willpower, personal choice and responsibility, have contributed to the limited success of medical approaches to smoking cessation. While the rapid uptake of e-cigarettes in some countries has provided an option for those who reject medical treatments for smoking cessation, current regulatory developments could limit the potential of e-cigarettes to provide non-therapeutic nicotine for those who currently smoke tobacco.

Views and Preferences for Nicotine Products as an Alternative to Smoking: A Focus Group Study of People Living with Mental Disorders

Aims and Background: People living with mental disorders experience a disproportionately higher burden of tobacco-related disease than the general population. Long-term substitution with less harmful nicotine products could reduce the tobacco-related harm among this population. This study investigated the views and preferences of people with mental health disorders about different nicotine products and their use as long-term substitutes for cigarettes. Methods: Semi-structured focus group discussion followed by a brief questionnaire. The discussion transcripts were analysed for content and themes and quantitative data summarised with descriptive statistics. Results: Twenty-nine participants took part in four focus groups. Vaping devices were the most acceptable nicotine products discussed; however preferences for nicotine products were individual and varied along aesthetic, pragmatic, sensory and symbolic dimensions. The concept of tobacco harm reduction was unfamiliar to participants, however they generally agreed with the logic of replacing cigarettes with less harmful nicotine products. Barriers to activating tobacco harm reduction included the symbolism of smoking and quitting; the importance placed on health; the consumer appeal of alternatives; and cost implications. Discussion and Conclusions: Engaging this population in tobacco harm reduction options will require communication that challenges black and white thinking (a conceptual framework in which smoking cigarettes or quitting all nicotine are the only legitimate options) as in practice this serves to support the continuance of smoking. Consumers should be encouraged to trial a range of nicotine products to find the most acceptable alternative to smoking that reduces health harms. Providing incentives to switch to nicotine products could help overcome barriers to using less harmful nicotine products among mental health consumers.

Everyday tactics in local moral worlds: E-cigarette practices in a working-class area of the UK

Research into e-cigarette use has largely focused on their health effects and efficacy for smoking cessation, with little attention given to their potential effect on health inequalities. Drawing on three years of ethnographic research between 2012 and 2015, I investigate the emerging e-cigarette practices of adult smokers and quitters in a working-class area of the UK. I first use de Certeau's notion of ‘tactics’ to describe the informal economy of local e-cigarette use. Low-priced products were purchased through personal networks and informal sources for financial reasons, but also as a solution to the moral problems of addiction and expenditure on the self, particularly for older smokers. E-cigarette practices were produced in local moral worlds where smoking and cessation had a complex status mediated through norms of age and gender. For younger men, smoking cessation conflicted with an ethic of working-class hedonism but e-cigarette use allowed cessation to be incorporated into male sociality. Continued addiction had moral implications which older men addressed by constructing e-cigarette use as functional rather than pleasurable, drawing on a narrative of family responsibility. The low priority which older women with a relational sense of identity gave to their own health led to a lower tolerance for e-cigarette unreliability. I draw on Kleinman's local moral worlds to make sense of these findings, arguing that smoking cessation can be a risk to moral identity in violating local norms of age and gender performance. I conclude that e-cigarettes did have some potential to overcome normative barriers to smoking cessation and therefore to reduce health inequalities, at least in relation to male smoking. Further research which attends to local meanings of cessation in relation to age and gender will establish whether e-cigarettes have similar potential elsewhere.

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Smokers and e-cigarette users bought cheap products for moral and financial reasons.

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Smoking cessation conflicted with an ethic of hedonism but e-cigarettes did not.

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Older men saw e-cigarette use as functional in a narrative of family responsibility.

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Older women gave their health low priority and found e-cigarettes too much trouble.

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E-cigarettes had potential to overcome some normative barriers to smoking cessation.

E-Cigarettes Use Behavior and Experience of Adults: Qualitative Research Findings to Inform E-Cigarette Use Measure Development

OBJECTIVES

To gain a better understanding of electronic cigarette (e-cigarette) use behavior and experience among adult e-cigarette users, with the goal of informing development of future e-cigarette use measures.

METHODS

Between August and October 2014 six focus groups were conducted in Seattle. Participants (63% male; 60% >35 years old; 60% White): e-cigarette users who used combustible tobacco products either currently or in the past. E-cigarette discussion topics covered: their daily use pattern (eg, frequency), product-related characteristics (eg, nicotine levels), and perceptions about health risks and benefits.

RESULTS

Participants' descriptions of daily use were so varied that no common "unit" of a "session" easily summarized frequency or quantity of typical e-cigarette use. Most users had difficulty in tracking their own use. Participants reported nicotine craving relief when using e-cigarettes, but described e-cigarettes use as less satisfying than combustible cigarettes. Valued characteristics included "ready availability" and the possibility of using indoors. A unique aspect of the e-cigarette use experience is the option of adding flavors and having the ability to exhale "big clouds" of vapor/aerosol. Most perceived e-cigarettes as a better and safer alternative to conventional cigarettes, yet still sought further information about health consequences and safety of e-cigarettes from trusted sources.

CONCLUSIONS

E-cigarettes users are far from homogeneous in their behavior and motivation for adopting e-cigarettes. A range of use patterns arising from both hedonic and utilitarian factors, along with product characteristics (eg, variable nicotine levels and flavors) extending beyond those of conventional cigarettes, suggest that new, specific e-cigarette use measures must be developed.

IMPLICATIONS

The current study provides timely information on adult e-cigarette use behavior, which is a crucial step in measuring this new phenomenon and assessing the risks associated with using e-cigarette products. Our findings reveal that vaping is not a mere replacement for combustible cigarette smoking and that many users of e-cigarettes enjoy product characteristics such as flavors and "clouds" that are unavailable in combustible cigarettes. Therefore, commonly available cigarette smoking measures are not well suited to measurement of e-cigarette use behavior, and indication that new measures need to be developed to accurately track e-cigarette use.

How and Why Do Smokers Start Using E-Cigarettes? Qualitative Study of Vapers in London, UK

The aims of the study were to (1) describe how and why smokers start to vape and what products they use; (2) relate findings to the COM-B theory of behaviour change (three conditions are necessary for behaviour change (B): capability (C), opportunity (O), and motivation (M)); and (3) to consider implications for e-cigarette policy research. Semi-structured interviews (n = 30) were conducted in London, UK, with smokers or ex-smokers who were currently using or had used e-cigarettes. E-cigarette initiation (behaviour) was facilitated by: capability (physical capability to use an e-cigarette and psychological capability to understand that using e-cigarettes was less harmful than smoking); opportunity (physical opportunity to access e-cigarettes in shops, at a lower cost than cigarettes, and to vape in "smoke-free" environments, as well as social opportunity to vape with friends and family); and motivation (automatic motivation including curiosity, and reflective motivation, including self-conscious decision-making processes related to perceived health benefits). The application of the COM-B model identified multiple factors that may lead to e-cigarette initiation, including those that could be influenced by policy, such as price relative to cigarettes and use in smoke-free environments. The effects of these policies on initiation should be further investigated along with the possible moderating/mediating effects of social support.

E-cigarette use in adults: a qualitative study of users' perceptions and future use intentions

BACKGROUND

There has been an exponential increase in the prevalence of e-cigarette use, particularly among youth. However, adult use is also rising, and there have been relatively few qualitative studies with adult users to understand their reasons for use and future use intentions. Such information is needed to inform both prevention and cessation approaches.

METHOD

Thirty-one e-cigarette users participated in one of several focus groups assessing the appeal of e-cigarettes as well as comparisons to combustible cigarettes and approved smoking cessation aids. We also obtained perspectives on future use intentions and interest in e-cigarette cessation interventions. Verbatim transcripts were analyzed using the constant comparative method.

RESULTS

Participants reported several aspects of e-cigarette appeal as compared to approved cessation treatment options. These included similarities to combustible cigarettes, fewer side effects, and control of e-cigarettes to suit personal preferences. Participants were split on whether they preferred flavors that mimicked or contrasted with their combustible cigarettes (i.e., tobacco vs. alternative flavors, such as candy). Some participants who were unmotivated to quit smoking reported an unanticipated disinterest in continuing use of combustible cigarettes shortly after initiating e-cigarettes. Despite strong interest in reducing nicotine dosage, the majority did not intend to fully discontinue e-cigarettes.

CONCLUSIONS

Understanding e-cigarette users' perspectives can inform policy and treatment development. Regulatory and policy initiatives will need to balance the appealing characteristics of e-cigarettes with the potential for negative public health outcomes.