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

Concurrent E-cigarette Use While Enrolled in a Smoking Cessation Program: Associations Between Frequency of Use, Motives for Use, and Smoking Cessation

INTRODUCTION

Trial evidence suggests that e-cigarettes may aid in quitting smoking, while observational studies have found conflicting results. However, many observational studies have not adjusted for important differences between e-cigarette users and non-users.

AIMS AND METHODS

We aimed to determine the association between e-cigarette use frequency and motivation to use e-cigarettes to quit smoking, and smoking cessation using data from Canada's largest smoking cessation program. Participants who completed a baseline assessment and 6-month follow-up questionnaire were divided post hoc into four groups based on their self-reported e-cigarette use during the 30 days before baseline: (1) non-users; (2) users of e-cigarettes not containing nicotine; (3) occasional users; and (4) frequent users. Occasional and frequent users were further divided into two groups based on whether they reported using e-cigarettes to quit smoking. Abstinence at 6-month follow-up (7-day point prevalence abstinence) was compared among groups.

RESULTS

Adjusted quit probabilities were significantly higher (both p < .001) for frequent baseline e-cigarette users (31.6%; 95% CI = 29.3%, 33.8%) than for non-users (25.8%; 25.3% and 26.3%) or occasional users (24.2%; 22.5% and 26.0%). Unadjusted proportions favored non-users over occasional users (p < .001), but this was not significant after adjustment (p = .06). People using e-cigarettes to quit smoking were not likelier than other users to be successful, but were likelier to report frequent e-cigarette use during follow-up.

CONCLUSIONS

Frequent baseline e-cigarette use predicted successful smoking cessation, compared to occasional and non-users. Use of e-cigarettes to quit did not predict smoking cessation but was associated with continued use during follow-up, perhaps due in part to planned transitions to e-cigarettes.

IMPLICATIONS

Prior observational studies investigating e-cigarette use for smoking cessation have found that occasional users have poorer outcomes than either frequent or non-users. Consistent with these studies, occasional users in our data also had poorer outcomes. However, after adjustment for variables associated with cessation success, we found that cessation probabilities did not differ between occasional and non-users. These findings are consistent with trial data showing the benefit of e-cigarette use among people trying to quit smoking. Results of this study suggest that differences between trials and previous observational studies may be because of unaddressed confounding in the latter.

How has the brain disease model of addiction contributed to tobacco control?

Our paper evaluates the extent to which the brain disease model of addiction (BDMA) has contributed to reducing the prevalence of tobacco smoking and  tobacco-related harm over the past 20 years. We discuss the ways in which genetic and neuroscience research on nicotine addiction have contributed to our understanding of tobacco smoking. We then examine the extent to which the BDMA has produced more effective treatments to assist smoking cessation. We also assess the degree to which the BDMA has contributed to the tobacco control policies that have produced substantial reductions in tobacco-related morbidity and mortality in the two decades since the model was first proposed by Alan Leshner. We also assess whether the BDMA has reduced the stigmatisation of people who smoke tobacco.

It's addiction at this Point": A qualitative examination of youth E-cigarette use trajectory in the United States

E-cigarettes (electronic cigarettes) have been the most used tobacco product among US youth since 2014, reaching a plateau during the COVID-19 pandemic. Youth e-cigarette use is associated with negative health consequences such as impaired cognitive functioning. For many, the COVID-19 pandemic altered social interactions, harm perceptions, and product availability. This changed the frequency and locations in which youth use e-cigarettes. To better understand youth e-cigarette use, we need more information on factors that can alter e-cigarette use, specifically, how the pandemic changed e-cigarette use among youth. In 2020-2021, we conducted online, individual interviews with 19 youth (aged 13-17) e-cigarette users living in the US to explore how COVID-19 impacted their e-cigarette use. Youth described a progression of e-cigarette use from initial experimentation, regular social use, and ultimately to nicotine addiction demonstrated by individual use in isolation. Many youth initiated e-cigarette use due to influences by friends or family members. Youth discussed progression to social use, with social interactions as an important reason for use and an avenue for expanding one's knowledge of e-cigarettes. After a period of time, youth began to recognize that the social interactions mattered less, suggesting to them that they had become addicted. This realization became more apparent during COVID-19, which changed how youth used e-cigarettes, especially around where use was occurring, health concerns, and use behavior and frequency. In our interviews, youth trajectory began with an initiation with family and friends, progressed to social use, and eventually developed to addiction, at which point social use was no longer the primary motivation for e-cigarette use. Understanding the trajectory of e-cigarette use will allow for effective interventions that reduce harm to youth from e-cigarette use.

Electronic Nicotine Delivery System flavor use over time by age group in the US: A longitudinal analysis

INTRODUCTION

The prevalence of flavor use in Electronic Nicotine Delivery Systems (ENDS) has been assessed in numerous studies, but limited research has focused on flavor use trends and maintenance of flavor preference over time. This study investigated the general trends and maintenance of ENDS flavor use for youth (aged 12-17 years), young adults (aged 18-24 years), and older adults (aged ≥25 years) between 2014 and 2019.

METHODS

Population Assessment of Tobacco and Health (PATH) Study Wave 2 (2014-2015), Wave 3 (2015-2016), Wave 4 (2016-2017), and Wave 5 (2018-2019) youth and adult data were used. Cross-sectional flavor use prevalence (trends) and flavor maintenance (using the same flavor category in at least three consecutive waves) were assessed.

RESULTS

The most reported primary flavor category was fruit among all age groups in all waves. Candy/desserts in waves two, three, four, and menthol/mint in wave five were the second most reported flavor in all age groups. The highest increase was observed for menthol/mint use among youth between wave two (21.9%) and five (58.1%) (OR=5.33; 95% CI: 3.58-7.96). Overall, 37.6% of fruit flavor users, 25.3% of candy/desserts users, 32.0% of menthol/mint users, and 33.4% of tobacco flavor users, maintained use of the same flavor in at least three consecutive waves.

CONCLUSIONS

Fruit flavor had the highest percentages of use and maintenance between 2014 and 2019. While the maintenance of fruit and candy/desserts flavors were higher among youth, adults had substantially higher maintenance percentages for menthol/mint and tobacco flavor. There was a substantial increase in menthol/mint use in wave five among youth, which may affect ENDS flavor maintenance patterns in the future. Understanding maintenance of flavors over time can inform regulation of ENDS flavors.

Changing Behaviour: Blindness to Risk and a Critique of Tobacco Control Policy in China—A Qualitative Study

(1) Background: It is well recognised that a focus on changing behaviour remains a dominant and often appealing approach to develop health policies. This study provides a sociological insight into young adults’ knowledge of the health effects of smoking cigarettes. We also examine the challenges in tobacco control and criticize the implementation policies in Chinese context. (2) Methods: The study applies both a micro-sociological and a macro-sociological approach using semi-structured interviews and documents as the primary research methodology. Fieldwork was conducted from July to September 2016 and December 2016 to March 2017. The qualitative study involved 45 semi-structured interviews with young adults aged 16–24 years (15 females and 30 males) in Tianjin, China. A grounded theory approach was used for a thematic analysis. (3) Results: The participants knew cigarettes are harmful, although they lacked a comprehensive understanding of the health risks of smoking. Because the health consequences usually emerge after a long period of smoking, young smokers decide to take the health risk. All participants have a general understanding of China’s tobacco control policies and think that the implementation is ineffective. (4) Conclusions: Changing in smoking is a process embedded in complex social environments and cultures. Smoking behaviour is not only a personal choice, but also related to personal connections with peers and identity in Chinese society. The Chinese government has made significant achievements in tobacco control since joining the WHO framework convention on tobacco control in 2005. However, implementation needs to be stricter in order to achieve international levels of control, especially in taxes on tobacco product and the price of cigarettes. There is an urgent need for the regulation of e-cigarettes in China.

Urgent Need for Novel Investigations of Treatments to Quit E-cigarettes: Findings from a Systematic Review

E-cigarette use has been increasing globally over the past decade. Many use e-cigarettes as an alternative or method to quit cigarette smoking, whereas others use these products recreationally. As technology has advanced, many individuals have reported symptoms of dependence on these products and continue to use them beyond achieving abstinence from smoking. Despite individuals reporting interest in quitting, little is known about e-cigarette cessation. This systematic review sought to identify and evaluate all human subjects literature published on the outcome of e-cigarette cessation through September 2021. Of the 79 articles identified, 56 were cross-sectional, 6 were qualitative, 5 were cohort studies, 3 were experimental, 2 were mixed methods, and 7 reported intervention or case studies of e-cigarette cessation. Results showed youth generally had high intent to quit e-cigarettes, whereas results were mixed with adult samples. Youth were motivated to quit e-cigarettes by health concerns, whereas adults were motivated to quit e-cigarettes by cost, lack of satisfaction, and psychologic factors. Adults were more likely to report past e-cigarette quit attempts, most commonly "cold turkey." Few interventions tested strategies for e-cigarette cessation, with a majority targeted for youth. Given the lack of information on e-cigarette cessation, recommendations for future studies are outlined.

Electronic Cigarette and Atherosclerosis: A Comprehensive Literature Review of Latest Evidences

Coronary artery diseases (CAD), also known as coronary heart disease (CHD), are the world’s leading cause of death. The basis of coronary artery disease is the narrowing of the heart coronary artery lumen due to atherosclerosis. The use of electronic cigarettes has increased significantly over the years. However, harmful effects of electronic cigarettes are still not firm. The aim of this article is to review the impact of electronic cigarette and its role in the pathogenesis of atherosclerosis from recent studies. The results showed that several chemical compounds, such as nicotine, propylene glycol, particulate matters, heavy metals, and flavorings, in electronic cigarette induce atherosclerosis with each molecular mechanism that lead to atherosclerosis progression by formation of ROS, endothelial dysfunction, and inflammation. Further research is still needed to determine the exact mechanism and provide more clinical evidence.

“It’s Like Jogging Next to the Highway”: A Qualitative Analysis of the Motivations and Experiences of Single-, Dual-, and Ex-Users of IQOS in The Netherlands

The popularity of heated tobacco products (HTPs) is of concern, as most users are dual users exposed to emissions of both HTPs and conventional cigarettes. Furthermore, HTPs may appeal to young people and non-smokers. This study aims to build intelligence on user experiences in order to inform policy development. We conducted five semi-structured focus group interviews with single-, dual-, and ex-users of the HTP IQOS. The discussions focused on initiation and use, experiences and perception, and knowledge and information needs. We performed a thematic analysis of the transcripts. All users smoked cigarettes and/or roll your own (RYO) tobacco before using HTP. We found that almost all users started using IQOS after being introduced to it by others. Single users successfully quit smoking cigarettes using the IQOS, liked the taste, and experienced physical benefits. Dual users experienced more satisfaction from smoking cigarettes and used the IQOS for specific occasions, such as social situations or in places with smoking bans. All IQOS users described themselves as smokers and considered using the IQOS as an alternative way of smoking. Regulators may consider providing reliable and easily accessible information and regulating points of sale, promotional activities, and product properties such as flavors and devices in order to reduce product attractiveness and discourage use.

Participant Experiences of a Quit Smoking Attempt Through Either Nicotine Replacement Therapy (NRT) Methods or the Use of an E-cigarette

OBJECTIVES

There is a lack of evidence exploring experiences of using e-cigarettes for smoking cessation. The study's main aim was to explore participant experiences of e-cigarettes compared to nicotine replacement therapy (NRT) delivered through stop smoking services.

METHODS

Semi-structured, face-to-face, and telephone interviews at 3-month post-quit follow-up in a randomized controlled trial comparing nicotine-containing e-cigarettes, nicotine-free e-cigarettes, and NRT for smoking cessation. N = 17 participants, 9 were male, mean age 44 years, 5 using nicotine-containing e-cigarettes, 7 nicotine-free e-cigarettes, and 5 NRT. Interviews were transcribed and analyzed using thematic analysis.

RESULTS

Two global themes and 5 organizing themes were identified. Global themes included: (1) experiences of e-cigarette and NRT quit aids (e-cigarette positive impact and dilemmas, NRT perceptions and experiences), and (2) key mechanisms to support quit attempt (physical aids, advice and support, feedback and structure). E-cigarettes were viewed with caution, however, generally evaluated positively alongside NRT methods, finding e-cigarettes useful during a quit attempt due to their versatility in application. Nicotinecontaining e-cigarettes were favored due to their support with nicotine cravings. Participants were, however, wary of replacing smoking addiction with vaping habit.

CONCLUSIONS

Participant e-cigarette experience were generally positive; however, concerns over long-term application were noted. There was a noticeable preference for nicotine-containing e-cigarettes, but further research is required to better understand how nicotine is used in conjunction with e-cigarettes long-term as a quit aid alongside other NRT.

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.

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.

From gateways to multilinear connections: A qualitative longitudinal investigation of the relationships between vaping and smoking among adolescent users

BACKGROUND

The international growth of e-cigarette use has been accompanied by a corresponding concern that e-cigarettes will act as a 'gateway' to smoking and the use of other drugs. Taking these concerns as our point of departure, we explore the relationships between vaping and smoking among a cohort of young people.

METHODS

Qualitative longitudinal methods with a diverse sample of 36 14-18-year olds from the UK city of Leicester. A total of 66 depth interviews conducted across two phases separated by 6-12 months. The interviews were recorded, transcribed verbatim and thematically analysed.

FINDINGS

We highlight a complex 'tangle' of connections between substances/risk behaviours recounted to us by our adolescent study participants, including multiple and multilinear relationships between vaping and smoking. These findings problematise some of the core axioms of the notion of gateways as an explanatory model of causality and sequential connection between smoking and vaping. They also throw into question gateway logics more fundamentally. While many of our study participants themselves consciously invoked ideas of 'gateway effects', the accounts they produced repeatedly disrupted the logics of connection (between e-cigarettes and smoking; one set of behaviours and another) presupposed in gateway theory and our own early lines of questioning. Accordingly, we explore how cultural understandings of gateway effects are invoked by users in accounting for their vaping and smoking behaviours, noting the potential influence of these ideas upon the very processes they are understood to apprehend.

CONCLUSION

Our findings suggest there is a case to be made to reinforce the distinctiveness of tobacco and e-cigarettes in the life-worlds of young people to avoid naturalising a 'gateway' logic of connection that might ultimately inform the associative logic of young users themselves, and potentially the development of their usage careers.

Gender Differences in Reasons for Using Electronic Cigarettes and Product Characteristics: Findings From the 2018 ITC Four Country Smoking and Vaping Survey

INTRODUCTION

Little is known about why males are more likely to use electronic cigarettes (ECs) compared with females. This study examined gender differences in reasons for vaping and characteristics of EC used (device type, device capacity, e-liquid nicotine strength, and flavor).

METHODS

Data were obtained from 3938 current (≥18 years) at-least-weekly EC users who participated in Wave 2 (2018) ITC Four Country Smoking and Vaping Survey in Canada, the United States, England, and Australia.

RESULTS

Of the sample, 54% were male. The most commonly cited reasons for vaping in females were "less harmful to others" (85.8%) and in males were "less harmful than cigarettes" (85.5%), with females being more likely to cite "less harmful to others" (adjusted odds ratio [aOR] = 1.64, p = .001) and "help cut down on cigarettes" (aOR = 1.60, p = .001) than males. Significant gender differences were found in EC device type used (χ  2 = 35.05, p = .043). Females were less likely to report using e-liquids containing >20 mg/mL of nicotine, and tank devices with >2 mL capacity (aOR = 0.41, p < .001 and aOR = 0.65, p = .026, respectively) than males. There was no significant gender difference in use of flavored e-liquids, with fruit being the most common flavor for both males (54.5%) and females (50.2%).

CONCLUSION

There were some gender differences in reasons for vaping and characteristics of the product used. Monitoring of gender differences in patterns of EC use would be useful to inform outreach activities and interventions for EC use.

IMPLICATIONS

Our findings provide some evidence of gender differences in reasons for vaping and characteristics of EC used. The most common reason for vaping reported by females was "less harmful to others," which may reflect greater concern by female vapers about the adverse effects of secondhand smoke compared with male vapers. Gender differences might be considered when designing gender-sensitive smoking cessation policies. Regarding characteristics of EC products used, we found gender differences in preferences for e-liquid nicotine strength and device capacity. Further studies should examine whether the observed gender differences in EC use reasons and product characteristics are predictive of smoking cessation. Furthermore, studies monitoring gender-based marketing of ECs may be considered.

Dependence and Use Characteristics of Adult JUUL Electronic Cigarette Users

JUUL is a popular electronic cigarette (e-cig) that is capable of delivering nicotine similarly to a cigarette. While known to deliver high doses of nicotine, there is little systematic evidence to show how the nicotine delivery of JUUL translates to user dependence. Purpose: The purpose of the study was to evaluate self-reported dependence of JUUL users and examine the relationship of dependence to user behaviors. Methods: Current JUUL users were recruited via Amazon Mechanical Turk to complete an online survey about their use of JUUL. Participants were asked to complete the Penn State Electronic Cigarette Dependence Index (PSECDI) and to answer questions about their use patterns and other tobacco use. Means and frequencies were used to describe the sample. A linear regression model was used to predict user dependence. Results: Participants (n = 76) were 65.4% male with a mean age of 31.9 (SD = 8.3) years. The mean PSECDI score was 7.8 (SD = 4.2) and ranged from no (15.8%) to high (14.5%) dependence. Overall predictors of a greater PSECDI score included reporting ever stealth vaping (β = 2.8, p < .01) and reporting greater use days in the past 30 (β = 3.5, p < .01). Conclusions: On average, JUUL users reported low to medium nicotine dependence on the PSECDI. JUUL user dependence may be more similar to e-cig user dependence than cigarette smoker dependence. These preliminary findings should be followed up in studies of larger samples of Juul users, collecting multiple measures of dependence, as well as biomarkers of nicotine intake (e.g. cotinine).

Why do people start or stop using e-cigarettes in Australia? A qualitative interview-based study

ISSUE ADDRESSED

E-cigarette awareness and use has increased globally, but little is known about the social factors that influence uptake in Australia. We explored the reasons why people started, continued and stopped using e-cigarettes in Australia.

METHODS

This was a qualitative study comprising 14 semi-structured interviews with past and current e-cigarette users in Australia. Interview transcripts were analysed thematically to explore reasons why people started, continued or stopped using e-cigarettes.

RESULTS

The following three themes emerged from interviews: "social" reasons, including issues of peer influence and social norms; "health" reasons, with aspects related to the reduction in use of cigarettes and health effects of using e-cigarettes; and "access and other personal" reasons, including the cost of e-cigarettes, the ability to access e-cigarettes and participants' experiences with e-cigarettes.

CONCLUSIONS

The study revealed that social norms and peer influence were reasons why people started and stopped using e-cigarettes. Smokers often cited health reasons for starting, while non-smokers cited social reasons for both starting and stopping. SO WHAT?: The social and non-social reasons for why people say they start or stop using e-cigarettes appear to vary between smokers and non-smokers. Future studies may benefit from measuring these factors, differentiating between smokers and non-smokers, and considering these factors as part of interventions for limiting e-cigarette uptake among non-smokers.

The Impact of E-liquid Propylene Glycol and Vegetable Glycerin Ratio on Ratings of Subjective Effects, Reinforcement Value, and Use in Current Smokers

INTRODUCTION

Electronic nicotine delivery systems (ENDS) vary on a wide range of characteristics that may affect reinforcement value and use. One characteristic is the ratio of two solvents commonly used in most e-liquids: propylene glycol (PG) and vegetable glycerin (VG). The goal of this study was to understand how PG/VG ratio affects subjective effects, reinforcement value, and tobacco use patterns among current smokers who try using ENDS.

AIMS AND METHODS

Current smokers with minimal ENDS use history (n = 30) sampled, in a double-blind fashion, three different e-liquids that varied in PG/VG ratio (70/30, 50/50, 0/100) while holding constant other aspects of the e-liquid and ENDS. Participants tried each e-liquid before rating the subjective effects on a modified version of the Cigarette Evaluation Questionnaire. Reinforcement value was assessed using a preference task where participants chose between the three e-liquids. The impact of each e-liquid on cigarette reinforcement was assessed using a modified version of the Cigarette Purchase Task. Participants were randomly assigned to receive one e-liquid to take home for 1 week.

RESULTS

PG/VG ratio had minimal impact on most of the tested outcomes. Participants rated the highest PG concentration as having a stronger "throat hit" than the other two. There was no significant difference between the number of participants who preferred each of the PG/VG ratios in the preference assessment. PG/VG ratio did not affect cigarette or ENDS use during the sampling week.

CONCLUSIONS

These data suggest that PG/VG ratio has minimal impact on subjective effects and reinforcement value in ENDS naive current smokers.

IMPLICATIONS

These data suggest that PG/VG ratio, within the range that is commonly used, has minimal impact on subjective effects, reinforcement value, or uptake in current smokers with minimal ENDS experience.

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.

How Does Smoking and Nicotine Dependence Change After Onset of Vaping? A Retrospective Analysis of Dual Users

INTRODUCTION

Although some smokers switch to exclusive use of electronic cigarettes (e-cigarettes), others become dual users of combustible cigarettes and e-cigarettes. Little is known about how the onset of vaping affects the use of and dependence on combustible cigarettes or total nicotine use and dependence, which may influence health-related and cessation outcomes. Using self-report data of current combustible and e-cigarette use and retrospective recall of pre-vaping smoking in a sample of dual users, the aims of this study were (1) to compare pre- and post-vaping number of cigarettes per day and combustible cigarette dependence; (2) to compare pre- and post-vaping total nicotine use frequency (number of vaping sessions and cigarettes smoked per day), and total nicotine dependence; and (3) to examine predictors of nicotine dependence.

METHODS

We used baseline data from a smoking cessation trial with 2896 dual users. Nicotine use frequency and the Heaviness of Smoking Index were used as measures of nicotine use and dependence, respectively.

RESULTS

Participants decreased cigarettes/day from pre- (M = 19.24, SD = 9.01) to post-vaping (M = 11.15, SD = 8.02, p < .0001) and combustible cigarette dependence declined from pre- (M = 3.55, SD = 1.51) to post-vaping (M = 2.11, SD = 1.60, p < .0001). Total daily nicotine use frequency increased after initiating vaping (M = 19.25, SD = 9.01 vs. M = 29.46, SD = 8.61; p < .0001), as did total nicotine dependence (M = 3.55, SD = 1.51 vs. M = 4.68, SD = 1.38; p < .0001). Hierarchical regression analyses indicated that variables associated with greater overall nicotine dependence included: younger age, lower education, more years smoking, higher pre-vaping nicotine dependence, using e-cigarettes more days per month, more puffs per vaping session, higher e-liquid nicotine concentration, and longer vaping history.

CONCLUSIONS

Dual use leads to a reduction in the number of combustible cigarettes, but total nicotine use and dependence increases.

IMPLICATIONS

In dual users, a reduction in smoking following onset of vaping may offer some harm reduction via reduction in cigarette intake. However, the increase in total nicotine use and dependence could affect the ability to quit either or both products.

Role of flavours in vaping uptake and cessation among New Zealand smokers and non-smokers: a cross-sectional study

BACKGROUND

Concerns about the effects of vaping have prompted calls to restrict e-cigarette flavours. Vaping proponents have criticised these proposals, which they argue may discourage smokers from taking up vaping or trigger relapse to smoking. We explored the role flavours play in vaping uptake and cessation among New Zealand cigarette smokers and vaping-susceptible never smokers (VSNS), and examined current vapers' preferred flavours.

METHODS

We conducted an online survey of 1005 New Zealanders aged 18-70 years that included 324 current vapers (vaped in the last 30 days) and 302 'past' vapers (reported past vaping, but not within the last month). We asked respondents their reasons for vaping and explored current vapers' preferred e-cigarette flavours; we analysed the data using descriptive statistics and logistic regression.

RESULTS

Irrespective of smoking status, flavour was one of the main reasons respondents gave for vaping (smokers 83%; former smokers 77%; VSNS 80%). Flavour was less important to former vapers; 47% of smokers, 57% of former smokers and 64% of VSNS cited flavour as a reason for originally taking up vaping. Fruit flavours were most popular among all three groups; smokers also favoured tobacco flavour, while former smokers also favoured mint or menthol, and never smokers also favoured confectionery/sweets/lolly flavours.

CONCLUSIONS

Flavours play a major role in vaping initiation for current smokers, former smokers and vaping-susceptible non-smokers, and remain important to those who continue vaping. Our findings highlight the need for regulation that allows some flavour diversity without the extravagant marketing currently used to promote vaping and e-liquids.

Short-term E-cigarette toxicity effects on brain cognitive memory functions and inflammatory responses in mice

Exposure to cigarette smoke (CS) is associated with an increased risk of several neurological diseases such as stroke, Alzheimer's disease, and dementia. At present, commercialization of E-cigarettes (ECs) is increasing, and they are advertised as a less harmful nicotine-delivery system. There are, however, limited studies regarding the neurotoxicity effects of ECs on the brain, which remains a subject of debate. In the present study, we aimed to evaluate the in vivo effects of short-term EC vapor exposure on the brain and compare them with the effects of cigarette smoke (CS). BALB/c mice were exposed to air, CS, and EC for 14 days. We then assessed the inflammatory responses, oxidative stress, and cognitive functions of the mice by using maze tests. Cognitive spatial tests showed that the mice exposed to CS and ECs had delayed time in finding food rewards. EC exposure demonstrated no improvement in spatial memory learning to find the food reward on the next day. This implies that CS and EC exposure possibly causes damage to the olfactory system. Notably, EC exposure potentially causes abnormalities in mice memory functions. Histological staining of the cerebral cortex of mice brain in the EC-exposed group demonstrated inflammatory responses such as necrosis and cytoplasm vacuolization. Immunohistochemical staining revealed high expression of proinflammatory cytokine TNF-α in both the EC- and CS-exposed groups. Hence, we conclude that ECs share similar toxicity profiles as CS, which potentially negatively impact brain function.

A Summary of In Vitro and In Vivo Studies Evaluating the Impact of E-Cigarette Exposure on Living Organisms and the Environment

Worldwide use of electronic cigarettes has been rapidly expanding over recent years, but the long-term effect of e-cigarette vapor exposure on human health and environment is not well established; however, its mechanism of action entails the production of reactive oxygen species and trace metals, and the exacerbation of inflammation, which are associated with potential cytotoxicity and genotoxicity. The present study examines the effects of selected liquid chemicals used in e-cigarettes, such as propylene glycol/vegetable glycerin, nicotine and flavorings, on living organisms; the data collected indicates that exposure to e-cigarette liquid has potentially detrimental effects on cells in vitro, and on animals and humans in vivo. While e-liquid exposure can adversely influence the physiology of living organisms, vaping is recommended as an alternative for tobacco smoking. The study also compares the impact of e-cigarette liquid exposure and traditional cigarette smoke on organisms and the environmental impact. The environmental influence of e-cigarette use is closely connected with the emission of airborne particulate matter, suggesting the possibility of passive smoking. The obtained data provides an insight into the impact of nicotine delivery systems on living organisms and the environment.

The role of flavors in vaping initiation and satisfaction among U.S. adults

BACKGROUND

The prevalence of electronic cigarette use has grown over the past decade, with some users reportedly initiating e-cigarette use primarily due to flavors. This study examined the role of flavors in initiation among adult e-cigarette users, as well as the association of flavors with satisfaction and perceived addiction to vaping.

METHODS

The analysis sample consisted of 1492 current e-cigarette users aged 18 or older, drawn from an online quantitative survey conducted in 2016. Multivariable logistic regression and general linear models were used.

RESULTS

Most current e-cigarette users (62.9%) typically used flavors other than tobacco (including fruit, mint/menthol, sweet, candy, coffee and other), 24.2% typically used tobacco flavors, and 12.9% typically used non-flavored e-cigarettes. Flavor was a common reason for vaping initiation, selected by 29.5% of the sample. Flavor, particularly fruit flavor, was more likely to motivate young adults 18-24 to initiate vaping compared adults 35-44. Those who used flavors, particularly mint/menthol and flavors other than tobacco flavor, had higher odds of reporting high satisfaction with vaping and had higher odds of perceived addiction to vaping than respondents who did not use flavored e-cigarettes.

CONCLUSIONS

Users of flavored e-cigarettes reported greater satisfaction and self-perceived addiction than users of non-flavored e-cigarettes. The appeal of flavors, particularly among young adults, has implications for regulatory policy regarding the marketing and promotion of flavored products. These findings may provide direction for the Food and Drug Administration's plans to restrict flavors other than menthol, mint, and tobacco.

Effects of flavoring compounds used in electronic cigarette refill liquids on endothelial and vascular function

Electronic cigarette refill liquids are commercially provided with a wide variety of flavoring agents. A recent study suggested that several common flavors may scavenge nitric oxide (NO) and cause endothelial dysfunction. It was the aim of the present study to investigate the effects of these flavors on NO/cyclic GMP-mediated signaling and vascular relaxation. We tested the flavoring agents for effects on Ca²⁺-induced cGMP accumulation and NO synthase activation in cultured endothelial cells. NO scavenging was studied with NO-activated soluble guanylate cyclase and as NO release from a NO donor, measured with a NO electrode. Blood vessel function was studied with precontracted rat aortic rings in the absence and presence of acetylcholine or a NO donor. Cinnamaldehyde inhibited Ca²⁺-stimulated endothelial cGMP accumulation and NO synthase activation at ≥0.3 mM. Cinnamaldehyde and diacetyl inhibited NO-activated soluble guanylate cyclase with IC₅₀ values of 0.56 (0.54–0.58) and 0.29 (0.24–0.36) mM, respectively, and caused moderate NO scavenging at 1 mM that was not mediated by superoxide anions. The other compounds did not scavenge NO at 1 mM. None of the flavorings interfered with acetylcholine-induced vascular relaxation, but they caused relaxation of pre-contracted aortas. The most potent compounds were eugenol and cinnamaldehyde with EC₅₀ values of ~0.5 mM. Since the flavors did not affect endothelium-dependent vascular relaxation, NO scavenging by cinnamaldehyde and diacetyl does not result in impaired blood vessel function. Although not studied in vivo, the low potency of the compounds renders it unlikely that the observed effects are relevant to humans inhaling flavored vapor from electronic cigarettes.

Trends of Lipophilic, Antioxidant and Hematological Parameters Associated with Conventional and Electronic Smoking Habits in Middle-Age Romanians

It is known that cigarette smoking is correlated with medical associated inquires. New electronic cigarettes are intensively advertised as an alternative to conventional smoking, but only a few studies demonstrate their harmful potential. A cross-sectional study was designed using 150 subjects from Brasov (Romania), divided into three groups: non-smokers (NS = 58), conventional cigarettes smokers (CS = 58) and electronic cigarettes users (ECS = 34). The aim of this study was to determine levels of some plasma lipophilic and hematological components, and the total antioxidant status that could be associated with the smoking status of the subjects. Serum low density lipoproteins (LDL) cholesterol increased significantly for ECS participants versus NS group (18.9% difference) (p < 0.05). Also, the CS group is characterized by an increase of serum LDL cholesterol (7.9% difference vs. NS), but with no significant statistical difference. The variation of median values of serum very low density lipoproteins (VLDL) was in order NS < ECS < CS, with statistical difference between NS and CS groups (34.6% difference; p = 0.023). When comparing the antioxidant status of the three groups, significant differences (p < 0.05) were obtained between NS vs. CS and NS vs. ECS. Similar behavior was identified for CS and ECS. Statistically significant changes (p < 0.0001) for both vitamin A and vitamin E were identified in the blood of NS vs. CS and NS vs. ECS, and also when comparing vitamin A in the blood of the CS group versus the ECS group (p < 0.05). When all groups were compared, the difference in the white blood cell (WBC) was (p = 0.008). A slight increase in the red blood cell (RBC) count was observed, but with no statistical difference between groups. These results indicated that conventional cigarette and e-cigarette usage promotes the production of excess reactive oxygen species, involving different pathways, different antioxidants and bioactive molecules.

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.

Youth generated prevention messages about electronic cigarettes

Rates of e-cigarette use are high among youth, and there is little known about the long-term health effects of e-cigarettes. Since peer influence is a powerful determinant of tobacco use, we aimed to identify message themes about e-cigarettes that youth would use to encourage or discourage peers from using e-cigarettes. We conducted 10 focus groups (N = 69) with non-smokers and smokers from one middle school, high school and college in Connecticut. Participants engaged in a discussion about e-cigarettes, and each participant created one written message to encourage e-cigarette use and one to discourage use among peers. We content-analyzed the messages and identified three main themes and 12 encouraging and discouraging sub-themes. Encouraging themes included health benefits of e-cigarettes relative to cigarettes, attractive product characteristics (e.g. flavors) and social advantages (e.g. positive social image) of using e-cigarettes. Discouraging messages included health risks of e-cigarettes relative to cigarettes, unattractive product characteristics (e.g. cost) and social disadvantages (e.g. negative social image of using an e-cigarette). Overall, there were no differences by sex, age group or smoking status in generation of encouraging and discouraging message themes. This study identified youth-generated themes that may aid in e-cigarette prevention among youth.

Young adult dual combusted cigarette and e-cigarette users' anticipated responses to hypothetical e-cigarette market restrictions

Introduction: The aim of this exploratory study was to assess young adult dual e-cigarette (EC) and combusted cigarette (CC) users' anticipated responses to hypothetical market restrictions regarding key EC characteristics. Methods: Data came from 240 young adult dual EC and CC users recruited via Amazon Mechanical Turk in June 2017. Descriptive statistics were used to report sociodemographic, CC smoking, and EC use characteristics. McNemar's chi-square tests and chi-square tests were used to assess differences between groups in terms of anticipated responses to hypothetical EC market restrictions. Results: Hypothetical regulations resulted in reported intentions to reduce EC use and increase CC use; the greatest impact was found for restrictions regarding e-liquid nicotine content, followed by flavor and ability to modify EC devices. Moreover, individuals reporting use of flavored e-liquid, high nicotine content e-liquid, and customizable EC were most likely to report intentions to reduce EC use and increase CC use. Conclusions: This work provides preliminary evidence that restrictive regulations regarding key EC characteristics may increase intentions to increase CC use among young adult dual EC and CC users.

Cigarettes vs. E-Cigarettes: Policy Implications from a Focus Group Study

Background: Rates of electronic cigarettes (e-cigarette) use (vaping) have increased among college students over the past decade. Objectives: The current study sought to provide an in-depth examination of college students' beliefs about and attitudes toward cigarettes and e-cigarettes that may influence support/non-support of tobacco-free policies on college campuses and within their communities. Methods: Between August and December 2015, five focus groups (n = 22) were conducted at a large Southern University. Focus group discussions addressed social acceptance and areas where students commonly smoked/vaped on campus. Sessions were transcribed verbatim. Two researchers independently coded the transcripts and identified themes. A third researcher independently reviewed the coding and thematic analysis process (triangulation of researchers). Results: Participants expressed positive attitudes toward smoke-free policies that did not target college students, especially those that protected vulnerable populations (e.g., children). However, some were skeptical of tobacco-free policies that included e-cigarettes. Participants believed the campus tobacco-free policy had moved smokers' behavior off campus, but many reported seeing people vape in locations where smoking was not allowed (i.e., library, dorm rooms). Most perceived smoking to be less acceptable than vaping; smoking was described as 'dirty', while vaping was glamorized as a cultural trend. Conclusions/Importance: Findings from our qualitative study suggest that college students are supportive of smoke-free policies, but they are less supportive of comprehensive tobacco-free policies that include e-cigarettes. College campuses and surrounding communities should plan for education about policy protection via communication channels viewed frequently by students when including vaping devices in their comprehensive tobacco-free policies/ordinances.

E-cigarette use and perceived health change: Better health through vaping?

INTRODUCTION

As e-cigarette use increases, questions about individual and public health effects remain unanswered (e.g. cessation tool, addiction path). Despite increasing use, few studies have focused on vape shop patrons. This study examined whether vape shop patrons believe their health is affected by the use of e-cigs; more specifically, the aim was to evaluate the association between e-cig use, change in tobacco use, and perception of health.

METHODS

A survey of e-cig users (N=78) was conducted in vape shops. Questions included e-cig and traditional tobacco use, health perceptions, and demographics. Descriptive techniques were used to characterize participants as either those who perceived e-cig use improved their health or those who perceived their health unaffected. Logistic regression assessed the association between change in tobacco use, e-cig use, and perception of health effects.

RESULTS

Most reported daily e-cig (91%) and current (11.5%) or former (78.2%) combustible cigarette use. Approximately, three-fourths (76.9%) perceived better health; the remainder (23.1%) perceived unaffected health. Change in cigarette use was significantly associated with perceptions that health is better with e-cig use. Participants who decreased cigarette use by 2-3 cartons/month and more than 3 cartons/month were significantly more likely to indicate that e-cig use has improved their health compared to those who decreased tobacco use by 1.5 cartons or fewer per month (OR=4.35, 95% CI: 1.13-16.9; OR=25.67, 95% CI: 2.97-221.7, respectively).

CONCLUSIONS

The majority of e-cig users perceived better health. Our findings suggest that health campaign designers should carefully assess the scientific uncertainty surrounding the use of these devices and consider means to clearly convey this information. Given the lack of scientific agreement on the health effects of e-cigs and the important role that perceptions play in behavior, health campaign designers, health education practitioners, policy makers, and health care providers should err on the side of caution when advising individuals about e-cig use.

Using the Ecological Model to understand influences on college student vaping

Objective The Ecological Model was used to examine the social and environmental influences of the college environment on e-cigarette use (vaping) among college students.

PARTICIPANTS

Undergraduate college student e-cigarette users (vapers) across three large college campuses in the southwest US from Jan 2015- Aug 2016.

METHODS

Thirty-three interviews were conducted. Transcribed interviews were coded then analyzed for themes.

RESULTS

College student vapers report multiple levels of influence on their vaping beyond personal beliefs and peer influences, including parents, explicit campus and community messaging, community member requests, and respect for others. College student vapers also describe constant associations with smokers in allowable public places to vape.

CONCLUSIONS

Parents, community members, campus policy, and the physical environment all influence where and when college students vape. Health communication messages to prevent college student vaping should incorporate alternative messages that are important to college students, such as respect for others and social image.

The impact of restricting the use of e-cigarettes in public places: a systematic review

Background

We explored whether restrictions on using e-cigarettes in public places deter smokers from switching to e-cigarettes for harm reduction purposes. Secondary objectives looked at the ability to use e-cigarettes in public places as a reason for use and attitudes towards this among smokers.

Methods

Systematic review of the scientific and grey literature.

Results

No studies were found for the primary question. Twelve studies estimated the proportion of smokers citing the ability to use e-cigarettes in public places as a reason for use; estimates varied considerably but were typically higher for smokers than never smokers and lower for former than current smokers. Fourteen studies reported attitudes towards restrictions in public places. Smokers were significantly more likely to support the use of e-cigarettes in public places than never smokers and former smokers significantly less likely to support their use than current smokers.

Conclusions

There is a gap in the evidence base on whether restrictions on e-cigarettes in public places would deter smokers from switching for harm reduction purposes. The role that restrictions in public places play in smoker's choosing to vape, and the level of support for their use in public, is likely to vary between populations and by smoking status.

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.

Perceptions and Reasons Regarding E-Cigarette Use among Users and Non-Users: A Narrative Literature Review

This paper aims to provide an in-depth understanding of the attractiveness of e-cigarettes for several different groups. For this purpose, perceptions of and reasons for e-cigarette use were systematically reviewed as reported by e-cigarette users, cigarette smokers, dual users, and non-users, among both adults and youth. MEDLINE^&reg; and Scopus were used to search for relevant articles, and references of included studies were also investigated. Two reviewers screened all titles and abstracts independently, blinded to authors and journal titles (Cohen&rsquo;s Kappa = 0.83), resulting in 72 eligible articles. Risk perceptions, perceived benefits, and reasons for e-cigarette use were categorized in themes and sub-themes. Risk perceptions included harmfulness in general, and specific health risks. Perceived benefits included improved taste and smell, and safety for bystanders. Reasons for use included (health) benefits, curiosity, smoking cessation, and friends using e-cigarettes. The findings highlight that there is a variety of perceptions and reasons mentioned by adult and youth e-cigarette users, cigarette smokers, dual users, and non-users. As such, this overview provides valuable information for scientists, public health professionals, behavior change experts, and regulators to improve future research, risk communication, and possibilities to effectively regulate e-cigarettes.

Electronic cigarette use among patients with cancer: Reasons for use, beliefs, and patient-provider communication

OBJECTIVE

Smoking tobacco cigarettes after a cancer diagnosis increases risk for several serious adverse outcomes. Thus, patients can significantly benefit from quitting smoking. Electronic cigarettes are an increasingly popular cessation method. Providers routinely ask about combustible cigarette use, yet little is known about use and communication surrounding e-cigarettes among patients with cancer. This study aims to describe patterns, beliefs, and communication with oncology providers about e-cigarette use of patients with cancer.

METHODS

Patients with cancer (N = 121) who currently used e-cigarettes were surveyed in a cross-sectional study about their patterns and reasons for use, beliefs, and perceptions of risk for e-cigarettes, combustible cigarettes, and nicotine replacement therapies. Patient perspectives on provider communication regarding e-cigarettes were also assessed.

RESULTS

Most participants identified smoking cessation as the reason for initiating (81%) and continuing (60%) e-cigarette use. However, 51% of patients reported current dual use of combustible cigarettes and e-cigarettes, and most patients reported never having discussed their use of e-cigarettes with their oncology provider (72%). Patients characterized e-cigarettes as less addictive, less expensive, less stigmatizing, and less likely to impact cancer treatment than combustible cigarettes (Ps < .05), and more satisfying, more useful for quitting smoking, and more effective at reducing cancer-related stress than nicotine replacement therapies (Ps < .05).

CONCLUSIONS

Patients with cancer who use e-cigarettes have positive attitudes toward these devices and use them to aid in smoking cessation. This study also highlights the need for improved patient-provider communication on the safety and efficacy of e-cigarettes for smoking cessation.

A systematic review of consumer preference for e-cigarette attributes: Flavor, nicotine strength, and type

Objective

Systematic review of research examining consumer preference for the main electronic cigarette (e-cigarette) attributes namely flavor, nicotine strength, and type.

Method

A systematic search of peer-reviewed articles resulted in a pool of 12,933 articles. We included only articles that meet all the selection criteria: (1) peer-reviewed, (2) written in English, and (3) addressed consumer preference for one or more of the e-cigarette attributes including flavor, strength, and type.

Results

66 articles met the inclusion criteria for this review. Consumers preferred flavored e-cigarettes, and such preference varied with age groups and smoking status. We also found that several flavors were associated with decreased harm perception while tobacco flavor was associated with increased harm perception. In addition, some flavor chemicals and sweeteners used in e-cigarettes could be of toxicological concern. Finally, consumer preference for nicotine strength and types depended on smoking status, e-cigarette use history, and gender.

Conclusion

Adolescents could consider flavor the most important factor trying e-cigarettes and were more likely to initiate vaping through flavored e-cigarettes. Young adults overall preferred sweet, menthol, and cherry flavors, while non-smokers in particular preferred coffee and menthol flavors. Adults in general also preferred sweet flavors (though smokers like tobacco flavor the most) and disliked flavors that elicit bitterness or harshness. In terms of whether flavored e-cigarettes assisted quitting smoking, we found inconclusive evidence. E-cigarette users likely initiated use with a cigarette like product and transitioned to an advanced system with more features. Non-smokers and inexperienced e-cigarettes users tended to prefer no nicotine or low nicotine e-cigarettes while smokers and experienced e-cigarettes users preferred medium and high nicotine e-cigarettes. Weak evidence exists regarding a positive interaction between menthol flavor and nicotine strength.

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.

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.