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

Future nicotine use preferences of current cigarette smokers: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey

INTRODUCTION

Consumer preferences should be important factors that are considered when developing health policies and interventions. This paper examines the prevalence of, and factors associated with, consumer preferences regarding smoking behaviour 1 to 2 years in the future.

METHODS

At least weekly cigarette smokers in the 2020 wave of the International Tobacco Control Four Country Smoking and Vaping Survey (USA, Canada, England and Australia) (N = 8642) were asked if they preferred to continue to smoke or to quit with or without an alternative nicotine product (ANP) over the next 1-2 years.

RESULTS

Country-specific weighted data showed 21.5% preferred to continue smoking and 8.0% were uncertain, leaving 70.6% preferring to quit: 13.7% using an ANP and 56.9% completely quitting nicotine. Apart from interest in quitting, the main predictors of preferring to quit were history of vaping, being aged 55 and over, smoking weekly, worrying about smoking harms, regretting starting and believing vaping is less harmful relative to smoking. Among those preferring to quit, preferring to use ANPs in future was very strongly associated with current vaping (especially daily), being younger, living in England, reporting strong urges to smoke, believing vaping is much less harmful than smoking, and not strongly regretting starting to smoke, and not wanting to quit.

DISCUSSION AND CONCLUSIONS

A significant minority of smokers preferred not to quit, at least in the next year or two. Both interest in quitting and preference for ANPs over complete cessation were associated with similar covariates, including interest in vaping.

E-cigarette support for smoking cessation: Identifying the effectiveness of intervention components in an on-line randomized optimization experiment

AIMS, DESIGN AND SETTING

The aim of this study was to determine which combination(s) of five e-cigarette-orientated intervention components, delivered on-line, affect smoking cessation. An on-line (UK) balanced five-factor (2 × 2 × 2 × 2 × 2 = 32 intervention combinations) randomized factorial design guided by the multi-phase optimization strategy (MOST) was used.

PARTICIPANTS

A total of 1214 eligible participants (61% female; 97% white) were recruited via social media.

INTERVENTIONS

The five on-line intervention components designed to help smokers switch to exclusive e-cigarette use were: (1) tailored device selection advice; (2) tailored e-liquid nicotine strength advice; (3): tailored e-liquid flavour advice; (4) brief information on relative harms; and (5) text message (SMS) support.

MEASUREMENTS

The primary outcome was 4-week self-reported complete abstinence at 12 weeks post-randomization. Primary analyses were intention-to-treat (loss to follow-up recorded as smoking). Logistic regressions modelled the three- and two-way interactions and main effects, explored in that order.

FINDINGS

In the adjusted model the only significant interaction was a two-way interaction, advice on flavour combined with text message support, which increased the odds of abstinence (odds ratio = 1.55, 95% confidence interval = 1.13-2.14, P = 0.007, Bayes factor = 7.25). There were no main effects of the intervention components.

CONCLUSIONS

Text-message support with tailored advice on flavour is a promising intervention combination for smokers using an e-cigarette in a quit attempt.

Cigarette Smoking Abstinence Among Pregnant Individuals Using E-Cigarettes or Nicotine Replacement Therapy

Importance

Smoking cigarettes during pregnancy can impair maternal and child health, and pregnant individuals have increasingly used electronic cigarettes (e-cigarettes) for various reasons, including quitting smoking.

Objective

To assess smoking abstinence rates among pregnant individuals who used e-cigarettes compared with those who used nicotine replacement therapy (NRT).

Design, Setting, and Participants

This cohort study is a secondary data analysis of phase 8 of the US Pregnancy Risk Assessment Monitoring System, conducted between 2016 and 2020. Eligible participants included pregnant individuals who smoked combustible cigarettes within the 3 months before pregnancy and either used e-cigarettes or NRT during pregnancy. Data analysis was conducted from March 2022 to April 2023.

Exposures

Combustible cigarette use within 3 months before pregnancy and use of either e-cigarettes or NRT during pregnancy.

Main Outcomes and Measures

The primary outcome was the individual's self-reported smoking abstinence status during the last 3 months of pregnancy. Weighted percentages were reported and weighted multivariable logistic regression models were used to examine the association of e-cigarette use vs NRT with smoking abstinence. A propensity score was used to control for confounding by sociodemographics, pregnancy characteristics, prepregnancy smoking intensity, depression, behavioral support, and hookah use.

Results

The cohort included 1329 pregnant individuals (759 ≥25 years [60.2%]; 766 non-Hispanic White individuals [79.8%]) of whom 781 had an education level of high school or lower (61.4%), and 952 had an annual household income of $48 000 or less (81.5%). Of the 1329 individuals, 890 (unweighted percentage, 67.0%) were existing e-cigarette users, 67 (unweighted percentage, 5.0%) were new e-cigarette users, and 372 (unweighted percentage, 28.0%) were NRT users. Compared with individuals who used NRT during pregnancy, individuals who used e-cigarettes had a higher rate of smoking abstinence in late pregnancy (456 individuals [50.8%] vs 67 individuals [19.4%]; propensity score adjusted odds ratio [OR], 2.47; 95% CI, 1.17-5.20; P = .02). In the secondary analysis stratified by the timing of e-cigarette use initiation, existing users of e-cigarettes who initiated before pregnancy had a higher smoking abstinence rate than NRT users (446 users [53.1%] vs 67 users [19.4%]; adjusted OR, 2.61; 95% CI, 1.23-5.51; P = .01). However, new e-cigarette users who initiated use during pregnancy had a similar smoking abstinence rate in late pregnancy when compared with NRT users (10 users [20.6%] vs 67 users [19.4%]; adjusted OR, 1.13; 95% CI, 0.22-5.87; P = .88).

Conclusions and Relevance

These findings suggest that individuals who used e-cigarettes during pregnancy had a higher smoking abstinence rate in late pregnancy than individuals who used NRT, especially for those who initiated e-cigarette use before pregnancy, indicating that replacement of cigarettes with e-cigarettes during pregnancy may be a viable strategy for harm reduction.

How has Expenditure on Nicotine Products Changed in a Fast-Evolving Marketplace? A Representative Population Survey in England, 2018-2022

INTRODUCTION

In the last 5 years, there has been a dramatic shift in the types of nicotine products being purchased. This study aimed to estimate how much users spend on types of cigarettes and alternative nicotine products (e-cigarettes, nicotine replacement therapy (NRT), heated tobacco, and nicotine pouches) and describe changes between 2018 and 2022.

AIMS AND METHODS

Monthly representative cross-sectional survey in England. 10 323 adults who smoked cigarettes or used alternative nicotine reported their average weekly expenditure on these products, adjusted for inflation.

RESULTS

Smokers spent £20.49 [95% CI = 20.09-20.91] on cigarettes each week (£27.66 [26.84-28.50] and £15.96 [15.49-16.28] among those who mainly smoked manufactured and hand-rolled cigarettes, respectively), e-cigarette users spent £6.30 [5.99-6.55] (£8.41 [7.17-9.78], £6.42 [5.58-7.39], and £5.93 [5.64-6.30] among those who mainly used disposable, pod, and refillable devices, respectively), NRT users £6.11 [5.53-6.69], and heated tobacco users £13.87 [9.58-20.09]. Expenditure on cigarettes grew by 10% from September 2018 to July 2020, then fell by 10% from July 2020 to June 2022. These changes coincided with a 13% reduction in cigarette consumption and a 14% increase in the proportion mainly smoking hand-rolled cigarettes. Expenditure on e-cigarettes was stable between 2018 and late 2020, then rose by 31% up to mid-2022. Expenditure on NRT increased slowly in 2018-2020 (+4%) and more quickly thereafter (+20%).

CONCLUSIONS

Inflation-adjusted expenditure on cigarettes has fallen since 2020, such that the average smoker in England currently spends the same on cigarettes each week as in 2018. This has been achieved by smoking fewer cigarettes and switching to cheaper hand-rolled cigarettes. Expenditure on alternative nicotine has increased above inflation; users spent around a third more on these products in 2022 than between 2018-2020.

IMPLICATIONS

People in England continue to spend substantially more on smoking cigarettes than using alternative nicotine products. The average smoker in England spends around £13 a week (~£670 a year) more than people using only e-cigarettes or NRT. The average expenditure on manufactured cigarettes is double that of hand-rolled cigarettes.

Comparing the Effects of the EU- Versus the US-JUUL Pod in a Sample of UK Smokers: Nicotine Absorption, Satisfaction, and Other Nicotine-Related Subjective Effects

INTRODUCTION

Pod Vaping Devices (PVD) such as JUUL have become extremely popular in the United States although their uptake and use in the United Kingdom remain lower. A key difference between the United States and the United Kingdom is the nicotine strength legally permitted, typically 59 mg/mL in the United States but capped at 20 mg/mL in the United Kingdom and European Union. This may limit the ability of EU vaping devices to deliver satisfactory nicotine levels. The primary aim was to compare the EU- (18 mg/mL nicotine strength) with the U.S.-JUUL (59 mg/mL) on daily smokers' subjective experiences, craving relief, and blood nicotine levels.

AIMS AND METHODS

Double-blind, counterbalanced within-participants design with two conditions: 18 mg/mL versus 59 mg/mL. On two separate occasions, UK smokers (N =19, 10 males, 9 females) vaped ad libitum for 60 mins and provided blood samples at baseline 5, 15, 30, and 60 min. Subjective effects (incl. satisfaction) were measured at 10 and 60 min and, craving and withdrawal symptoms (WS) at baseline, 10 and 60 min.

RESULTS

Satisfaction did not differ between conditions. There was a significant interaction between Time and Nicotine concentration for Nicotine Hit (p = .045). Mean self-report of Nicotine Hit increased under the use of the 59 mg/mL from 10 to 60 min and decreased under the 18 mg/mL. Participants reported higher Throat Hits following use of the 59 mg/mL (p = .017). There were no differences in other subjective effects including craving, WS relief (ps > .05). Liquid consumption was doubled under the 18 versus the 59 mg/mL (p = .001) and nicotine boost was significantly higher in the 59 mg/mL at all time-points (p ≤ .001).

CONCLUSIONS

The results did not support our hypotheses that satisfaction, craving, and withdrawal reduction would be higher with the 59 mg/mL JUUL. This could be because of the doubling of liquid consumption in the 18 mg/mL. Whether satisfaction and craving relief persist over the longer-term outside of the lab remains to be determined.

IMPLICATIONS

In a 60-min ad-lib vaping session, the EU-JUUL was found to produce comparable satisfaction, craving- and withdrawal relief as the U.S.-JUUL in this sample of UK smokers. These findings could suggest that the higher nicotine concentrations available in PVDs in the United States are not necessary for providing satisfaction and improving craving and WS. However, this was at the expense of a considerable increase in liquid consumption indicative of compensatory puffing.

Exposure to secondhand aerosol from electronic cigarettes at homes: A real-life study in four European countries

Electronic cigarette (e-cigarette) use emits potentially hazardous compounds and deteriorates indoor air quality. Home is a place where e-cigarettes may frequently be used amid its increasing prohibition in public places. This study assessed the real-life scenario of bystanders' exposure to secondhand e-cigarette aerosol (SHA) at home. A one-week observational study was conducted within the TackSHS project in four countries (Greece, Italy, Spain, and the United Kingdom) in 2019 including: 1) homes of e-cigarette users living together with a non-user/non-smoker; and 2) control homes with no smokers nor e-cigarette users. Indoor airborne nicotine, PM2.5, and PM1.0 concentrations were measured as environmental markers of SHA. Biomarkers, including nicotine and its metabolites, tobacco-specific nitrosamines, propanediol, glycerol, and metals were measured in participants' saliva and urine samples. E-cigarette use characteristics, such as e-cigarette refill liquid's nicotine concentration, e-cigarette type, place of e-cigarette use at home, and frequency of ventilation, were also collected. A total of 29 e-cigarette users' homes and 21 control homes were included. The results showed that the seven-day concentrations of airborne nicotine were quantifiable in 21 (72.4 %) out of 29 e-cigarette users' homes; overall, they were quite low (geometric mean: 0.01 μg/m3; 95 % CI: 0.01-0.02 μg/m3) and were all below the limit of quantification in control homes. Seven-day concentrations of PM2.5 and PM1.0 in e-cigarette and control homes were similar. Airborne nicotine and PM concentrations did not differ according to different e-cigarette use characteristics. Non-users residing with e-cigarette users had low but significantly higher levels of cotinine, 3'-OH-cotinine and 1,2-propanediol in saliva, and cobalt in urine than non-users living in control homes. In conclusion, e-cigarette use at home created bystanders' exposure to SHA regardless of the e-cigarette use characteristics. Further studies are warranted to assess the implications of SHA exposure for smoke-free policy.

Do Social Norms for Cigarette Smoking and Nicotine Vaping Product Use Predict Trying Nicotine Vaping Products and Attempts to Quit Cigarette Smoking Amongst Adult Smokers? Findings From the 2016-2020 International Tobacco Control Four Country Smoking and Vaping Surveys

INTRODUCTION

To examine whether perceived injunctive and descriptive social norms towards cigarette and nicotine vaping product (NVP) use predicted subsequent trying NVPs and attempts to quit cigarette smoking amongst current smokers and whether associations varied across countries.

AIMS AND METHODS

Three waves of longitudinal cohort data from the International Tobacco Control Four Country Smoking and Vaping Survey were collected between 2016 and 2020 from 2290 adult smokers in Canada, Australia, England, and the United States who had never used NVPs at baseline (either wave 1 or wave 2) and followed up at the subsequent wave (wave 2 or wave 3, respectively) were analyzed using Generalized Estimating Equations.

RESULTS

Of the injunctive and descriptive norm measures for smoking and NVP use, NVP initiation was only independently predicted by the injunctive interpersonal norm for NVP use, with perceived approval of NVP use by important others predicting higher odds of trying NVPs (AOR = 1.65, 95% CI = 1.20 to 2.27). This predictive effect was independent of baseline quit intention with no country variations found. By contrast, making cigarette smoking quit attempts were independently predicted by both injunctive and descriptive interpersonal norms with perceived disapproval of smoking by important others (AOR = 1.65, 95% CI = 1.38 to 1.99) and close friends using NVPs (AOR = 1.37, 95% CI = 1.04 to 1.79), both associated with higher odds of smoking quit attempts.

CONCLUSIONS

Adult smokers who perceive NVP use as normative, either because such behavior is socially approved or common within their close social networks, appear more inclined to try NVPs or make smoking quit attempts than smokers who do not.

IMPLICATIONS

Social norms can shape a person's behavior and result in behavior change. This study shows that initiation of NVP use behavior among smokers can be reliably predicted by their perception of whether NVP use is acceptable to those important to them within their close social networks. Similarly, any attempts to stop cigarette smoking can be predicted by their perception of how acceptable cigarette smoking is among those who are important to them and whether any of their close friends use NVPs. Changing social norms towards cigarette smoking and NVP use could therefore be incorporated into smoking cessation interventions to help smokers to quit and/or switch to NVP use.

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.

What Helps and What Hinders the Creation of a Smoke-free Home: A Qualitative Study of Fathers in Scotland

INTRODUCTION

Few studies have explored fathers' views and experiences of creating a smoke-free home, with interventions largely targeting mothers. This study aimed to identify barriers and facilitators to fathers creating a smoke-free home, to inform future intervention development.

METHODS

Eighteen fathers who were smokers and lived in Scotland were recruited from Dads' community groups, Early Years Centres and through social media advertising. Semi-structured interviews explored their views and experiences of creating a smoke-free home. A theory-informed thematic analysis using the COM-B model highlighted ways in which capability, opportunity, and motivations shaped fathers' home smoking behaviors.

RESULTS

Several fathers understood the health risks of second-hand smoke exposure through public health messaging associated with recent smoke-free legislation prohibiting smoking in cars carrying children. Limited understanding of effective exposure reduction strategies and personal mental health challenges reduced some fathers' ability to create a smoke-free home. Fathers were keen to maintain their smoke-free home rules, and their motivations for this largely centered on their perceived role as protector of their children, and their desire to be a good role model.

CONCLUSIONS

Fathers' abilities to create a smoke-free home are shaped by a range of capabilities, opportunities, and motivations, some of which relate to their role as a father. Establishing a fuller understanding of the contextual and gender-specific factors that shape fathers' views on smoking in the home will facilitate the development of interventions and initiatives that fathers can identify and engage with, for the broader benefit of families and to improve gender equity and health.

IMPLICATIONS

Our findings can inform future development of father-centered and household-level smoke-free home interventions. They identify fathers' views and experiences and help reframe smoking in the home as a gendered family-wide issue, which is important in building consensus on how best to support parents to create a smoke-free home. Our findings highlight the need for additional research to develop understanding of the ways in which gender-related aspects of family structures, heterosexual relationships, and child living arrangements influence home smoking rules and how to tailor interventions accordingly.

Adolescents' Use of Nicotine-Free and Nicotine E-Cigarettes: A Longitudinal Study of Vaping Transitions and Vaper Characteristics

INTRODUCTION

Although adolescents' nicotine addiction from e-cigarettes is a concern, few studies differentiate between vaping with and without nicotine. This study examines the prevalence of nicotine and nicotine-free vaping, maps transitions between vaping behaviors, and assesses differences in the personal characteristics of vapers in a sample of Norwegian adolescents.

AIMS AND METHODS

Data came from a nationwide longitudinal study of adolescents (n = 2018) conducted in 2017 (T1), 2018 (T2), and 2019 (T3) (mean age: 14.2, 15.0, and 16.2). Using an online questionnaire, we measured vaping with and without nicotine, snus use, smoking, sensation-seeking, conduct problems, and levels of depression.

RESULTS

Past 12-month vaping prevalence was stable (12%, 13%, and 15%). Among adolescents reporting vaping at T1, 66% had used e-cigarettes without nicotine, 22% with nicotine, and 12% were unsure of nicotine content. Individual vaping trajectories were unstable: of nicotine-free vapers, 54% became non-users, while 14% became nicotine vapers from T1 to T2. From T2 to T3, 50% became non-users, while 17% became nicotine vapers. Of nicotine vapers, 39% became non-users from T1 to T2, while 46% became non-users from T2 to T3. Compared to nicotine-free vapers, nicotine vapers had more conduct problems (mean = 3.67 vs 2.17), had more symptoms of depression (mean = 11.38 vs 6.95), and comprised more past 30-day snus users (33% vs 14%) and cigarette users (33% vs 9%).

CONCLUSIONS

Adolescent vapers most commonly used e-cigarettes without nicotine, few of these transitioned into nicotine vaping, and a majority became non-users. Nicotine vapers were more likely to use other tobacco products and have more conduct problems and symptoms of depression compared to nicotine-free vapers.

IMPLICATIONS

Reporting the prevalence of nicotine-free vaping is critical for assessing nicotine exposure and subsequent risks of nicotine addiction. This multi-cohort longitudinal study showed that use of nicotine-free e-cigarettes is common among young vapers in Norway. Adolescents' vaping patterns-both with and without nicotine-are generally temporal and experimental. Despite the majority of nicotine vapers becoming non-users, they are characterized by having more conduct problems and poorer mental health, and they more often used other tobacco products.

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.

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.

Changes in puffing topography and subjective effects over a 2-week period in e-cigarette naïve smokers: Effects of device type and nicotine concentrations

INTRODUCTION

This study aimed to document changes in puffing topography and, the effects of device type and nicotine concentration on puffing topography, subjective effects and smoking behaviour over two weeks of e-cigarette (EC) use.

METHODS

EC naïve smokers (N = 50; 64% female) were randomly allocated to a cigalike (18 mg/mL) or tank containing either 18 (Tank18) or 6 mg/mL nicotine concentrations (Tank6). In 3 separate sessions (Baseline, 1 and 2 weeks post-baseline), participants vaped 20 min ad-libitum. Puff duration, puff number, inter-puff intervals (IPI), exhaled carbon monoxide (CO), cigarettes per day (CPD), cigarette dependence, craving, withdrawal, and subjective effects were recorded.

RESULTS

Two weeks post-baseline, puff duration and IPI significantly increased whilst puff number decreased. Cigalikes were associated with greater puff number and shorter IPI compared to Tanks; there was no difference between Tank18 and Tank6. CPD, CO and cigarette dependence reduced significantly from baseline to week1 but did not differ between conditions. During each session, there was a significant reduction in craving, whilst withdrawal symptoms were only alleviated in week1 and 2; there was no difference between conditions. Tank18 consistently rated highest on positive effects including satisfaction; satisfaction scores for Cigalikes and Tank6 declined overtime.

CONCLUSIONS

Cigalikes and tanks were both effective for reducing craving, withdrawal symptoms and CPD although for the former, this may only be achieved through more frequent puffing. That the Tank18 yielded greater satisfaction suggests tank devices and higher nicotine concentrations may be more suitable in the early stage of a smoking cessation attempt.

Perception and Behavior about Electric Cigarette in Electric Cigarette Users in Medan City, Indonesia

BACKGROUND: As a new device and technology, the use of e-cigarettes has increased rapidly in Indonesia, e-cigarettes attract and make people curious. AIM: This study aims to determine the description of perceptions and behavior about e- cigarettes in e-cigarette users in Medan city, Indonesia. METHODS: This type of research is quantitative with descriptive design. The sample of this study was 100 electric cigarette users in Medan city, Indonesia, using consecutive sampling method. The data in this study were obtained through a questionnaire conducted in August–October 2019. RESULTS: The respondents of this study were 100 electric cigarette users, consisting of 92 men and 8 women, aged between 17 and 39 years and 42% worked as students. Some respondents had more than 1 electric cigarette device and used different atomizers on different devices. As many as, 42% of tobacco smoking respondents switched to e-cigarettes and stopped smoking. There is a decrease in the number of tobacco cigarette consumption among users who use tobacco cigarettes and electric cigarettes, respondents who had a positive perception of e-cigarettes were 51%, and most of respondents (88%) use e-cigarettes because they see the people around them. CONCLUSION: This study shows that the majority of e-cigarette users in Medan city, Indonesia, are former smokers and have a positive perception of e-cigarettes. Moreover, the most frequent reasons to start using electric cigarette are because they see others around them use it.

A Qualitative Analysis of Maori and Pacific people's Experiences of Using Electronic Nicotine Delivery Systems (ENDS)

INTRODUCTION

If electronic nicotine delivery systems (ENDS) are to bring public health benefits, members of population groups most affected by smoking must find them an easily adopted and satisfying replacement for smoking. We explored experiences of ENDS uptake and use among Māori and Pacific peoples living in New Zealand and probed factors that assisted transitions from smoking to vaping.

METHODS

We recruited 16 participants using whānaungatanga and community advertising. All were aged 18 or over, identified as Māori or Pacific (or both), had smoked at least 100 cigarettes, and were current ENDS users. We undertook in-depth interviews and analyzed the data using a thematic analysis approach.

RESULTS

We identified two key challenges that participants reported facing: their search for a satisfying ENDS experience and resisting social cues that could trigger relapse. Two supportive factors facilitated and reinforced smoking to vaping transitions: improved financial and physical well-being, and feeling connected to vaping communities.

CONCLUSION

Learning about ENDS devices from those who had successfully switched from smoking to vaping provided much-needed information, reinforced the financial benefits of switching, and could inspire those making this transition to persist until they too become smoke free.

IMPLICATIONS

Measures to support transitions from smoking to ENDS use could reduce inequities in smoking prevalence that indigenous people experience. Collective cessation interventions that draw on communities' knowledge and connections may enable smokers to access support that helps them navigate the potentially complex pathway from smoking to vaping.

Factors that influence smokers' and ex-smokers' use of IQOS: a qualitative study of IQOS users and ex-users in the UK

BACKGROUND

One of the most widely available heated tobacco products is IQOS by Philip Morris International. However, there is a lack of independent research exploring IQOS initiation and subsequent use among smokers and ex-smokers.

AIMS

To (1) explore the reasons why smokers and ex-smokers use and continue/discontinue IQOS and (2) consider implications for future research and policy.

PARTICIPANTS

Adult (18+) current (n=22) and ex-users (n=8) of IQOS who either currently smoked or quit smoking in the last 2 years.

METHODS

Qualitative interview study in London, UK.

RESULTS

Six main factors influenced initiation and use of IQOS: (1) Health-wanting to reduce/quit smoking and perceptions of reduced harm (while understanding IQOS was not risk-free). Branded packaging, absence of pictorial warnings and physical health improvements conveyed reduced harm. (2) Financial-including high start-up costs, but cheaper ongoing costs than smoking. (3) Physical-mixed views on enjoyment and satisfaction. Sensory experiences influenced use including discreetness, cleanliness, reduced smell and tactile similarities relative to combustible cigarettes. (4) Practical-issues of accessibility, shortcomings with maintenance/operation limited ongoing use, whereas use in smoke-free places increased use. (5) Psychological-similarities in rituals and routines, although new practices developed to charge and clean; some liked trailblazing new technology. (6) Social-improved social interactions from using IQOS instead of smoking, but with more limited shared social experiences for some.

CONCLUSION

For some, IQOS facilitated smoking substitution. Factors such as packaging, labelling, risk communication, price and smoke-free policies appear to influence initiation and use.

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.

A Practice Theory Approach to Understanding Poly-Tobacco Use in the United States

This paper uses practice theory to explore a poorly understood phenomenon with important health implications: How and why an increasing number of young Americans regularly use multiple tobacco products. Practice theory is a promising alternative to traditional public health frameworks for understanding everyday activities related to health. It broadens the analytic focus from characteristics of individuals to viewing practices as having lives of their own in competing for, winning, and losing practitioners. We drew from in-depth interviews with 21 young adults (ages 18-29; California) who regularly use cigarettes, electronic nicotine delivery systems (ENDS), and/or smokeless tobacco. Participants described their everyday routines. We examined the characterizing elements of each tobacco product use practice and the roles of each within participants' routines. We found that each product comprises a distinct substance use practice with different roles to play in different situations and contexts. Notably, many participants rotated between or modulated use of different products as a strategy for reducing perceived tobacco-related harms. Cigarettes are uniquely capable of aiding in the space-time organization of everyday activities and coping with crisis, while ENDS and smokeless tobacco open up times and spaces for nicotine consumption. This kind of approach aids our understanding and anticipation of the evolution of tobacco use practices as new products and regulations are introduced.

Knowledge and Beliefs of Jordanian Community Toward E-cigarettes: A National Survey

Electronic nicotine delivery systems were promoted publically as a healthier replacement for conventional cigarettes. Knowledge and beliefs of the public can drive their behaviours to adapt or reject the new habit. No previous research was conducted in Jordan to assess electronic cigarettes (e-cigarettes) prevalence, and limited data are available on public opinions and orientation toward this new habit. To assess prevalence of, knowledge, attitude and beliefs about e-cigarettes, and examine factors associated with plans of quitting or initiating e-cigarettes among adults in Jordan. A large cross-sectional face-to-face survey on a random sample of adult population aged ≥ 18 years was conducted over two months to include 1820 adults in Jordan. A representative sample was collected using proportionate random sampling technique, which enabled us to geographically categorise the study population. Reliability and validity measures were taken to ensure a comprehensive and appropriate study tool. The Statistical Package for Social Science (SPSS®) version 24 was used to conduct descriptive analysis, logistic regression, and Rao-Scott chi-square. Findings were considered statistically significant at p value < 0.05 (with a confidence limit at 95%). Of 2164 adults approached, 1820 completed the questionnaire (84.1% response rate). The prevalence of current e-cigarette smokers and dual smokers were 11.7% and 4.0%, respectively. Quitting conventional smoking (38.8%) and enjoying the flavour (32.5%) were the most common reasons to start vaping. Friends were the major source of information about e-cigarettes. There was evidence that adults aged 45-59 years were less likely to be dual smokers (OR 0.51; 95%CI 0.29-0.66; p = 0.03). Poor knowledge about the content (23.7%) and types of e-cigarettes (14.5%) was reported. Plans to reduce or quit e-cigarettes were significantly associated with three factors: smokers' knowledge about its content, social impression, smokers' satisfaction with e-cigarettes. Social impression was also associated with plans of initiating e-cigarettes. Most participants thought vaping cannot be harmful to children and pregnant women (73.1%) and cannot be addictive (58.2%). Electronic cigarettes were considered helpful in smoking cessation by 69.1% of participants. The proportions of adults who were currently electronic cigarette and dual smokers were 11.7% and 4.0%, respectively. Our research may provide insight to product and individual factors that were associated with plans to sustain, quit or initiate electronic smoking.

Exposure to secondhand aerosol of electronic cigarettes in indoor settings in 12 European countries: data from the TackSHS survey

INTRODUCTION

Exposure to secondhand aerosol from e-cigarette (SHA) may pose harmful effects to bystanders. This study aims to investigate the prevalence, duration and determinants of SHA exposure in various indoor settings in 12 European countries.

METHODS

In 2017-2018, we conducted a cross-sectional study, the TackSHS survey, on a representative sample of the population aged ≥15 years in 12 European countries (Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania and Spain). We described the prevalence and duration of exposure to SHA in several indoor settings among 11 604 e-cigarette non-users. Individual-level and country-level characteristics associated with SHA exposure were also explored using multilevel logistic regression analyses.

RESULTS

Overall, 16.0% of e-cigarette non-users were exposed to SHA in any indoor setting at least weekly, ranging from 4.3% in Spain to 29.6% in England. The median duration of SHA exposure among those who were exposed was 43 min/day. 'Other indoor settings' (eg, bar and restaurant) was reported as the place where most of e-cigarette non-users were exposed (8.3%), followed by workplace/educational venues (6.4%), home (5.8%), public transportation (3.5%) and private transportation (2.7%). SHA exposure was more likely to occur in certain groups of non-users: men, younger age groups, those with higher level of education, e-cigarette past users, current smokers, those perceiving SHA harmless and living in countries with a higher e-cigarette use prevalence.

CONCLUSIONS

We found inequalities of SHA exposure across and within European countries. Governments should consider extending their tobacco smoke-free legislation to e-cigarettes to protect bystanders, particularly vulnerable populations such as young people.

TRIAL REGISTRATION NUMBER

NCT02928536.

Understanding decisions to use e-cigarettes or behavioural support to quit tobacco: a qualitative study of current and ex-smokers and stop smoking service staff

AIM

To examine factors influencing current and ex-smokers' decisions to use e-cigarettes or behavioural support, including potential impacts of any differences in perspectives between smokers and their local stop smoking services (SSSs).

DESIGN

Semi-structured qualitative interviews followed by framework analysis, with the 'capability', 'opportunity', 'motivation' and 'behaviour' (COM-B) model of behaviour change used to frame findings.

SETTING

SSSs and surrounding local areas in England.

PARTICIPANTS

Interviewees (n = 46) were current or recent smokers (n = 29) and SSS staff or stakeholders (n = 17).

MEASUREMENTS

Interview topic guides explored influences on smokers' choice of quit method and characteristics of support offered by local SSSs.

FINDINGS

Current and ex-smokers showed a range of views on potential risks from long-term vaping, which appeared to be particularly relevant for the capability dimension of COM-B. These different attitudes to vaping appeared to be linked to variations in people's perceived capability to assess evidence around e-cigarettes' safety. Motivations for using or avoiding e-cigarettes and SSSs often appeared to overlap: attitudes to both e-cigarettes and nicotine replacement therapy from SSSs often reflected personal experiences and views on whether switching from smoking to these alternatives represented successful quitting or simply ongoing nicotine addiction. For smokers, opportunities to use e-cigarettes or SSSs appeared to be largely determined by perceived time requirements. Furthermore, interviews with SSS professionals suggested that opportunities to access SSSs for ex-smokers who were now regular vapers may be being influenced by different e-cigarette policies adopted in individual areas.

CONCLUSIONS

In England, smokers' decisions to use e-cigarettes and local stop smoking services appear to be determined by varied influences across the COM-B framework. Both smokers and stop smoking service professionals display diverse views about potential risks from e-cigarettes, which has relevance for the provision of behavioural support as well as the uptake of vaping.

Social Influence in the Uptake and Use of Electronic Cigarettes: A Systematic Review

CONTEXT

E-cigarettes were introduced to support smoking cessation, but their popularity has increased among nonsmokers, challenging current perspectives on their safety and effectiveness as a public health intervention. The objective of this systematic review was to identify and synthesize current evidence on the influence of social factors on e-cigarette intentions and use.

EVIDENCE ACQUISITION

MEDLINE, CINAHL, PsycINFO, and Embase were searched for studies of the effects of social factors on e-cigarette intention or use in February 2019. Studies were included if they used experimental, longitudinal, qualitative, or mixed methods designs. Advertising, social interactions, and social norms were considered as social factors; social media was considered a conduit for other social factors. Two reviewers screened all studies; bias risk was evaluated for all RCTs using the Cochrane risk of bias tool.

EVIDENCE SYNTHESIS

This review included 43 studies: 9 experimental, 11 longitudinal, 22 qualitative, and 1 mixed method. All experimental studies examined advertising and consistently showed that exposure increased intentions to use e-cigarettes. Evidence of the influence of social interactions and social norms came from longitudinal and qualitative studies, suggesting that these factors could increase e-cigarette use. Most participants were nonsmokers (81%; 22,233 of 27,303). Studies rarely considered differences in the effects of social factors on smokers and nonsmokers.

CONCLUSIONS

Given the increased popularity among nonsmokers and the potential for advertising to increase e-cigarette use, closer public health monitoring of e-cigarette uptake by nonsmokers is warranted. Future primary research should be designed to measure how social factors affect smokers and nonsmokers differently.

Mental health professionals' perceptions, judgements and decision-making practices regarding the use of electronic cigarettes as a tobacco harm reduction intervention in mental healthcare: A qualitative focus group study

BACKGROUND

Smoking prevalence remains significantly higher among individuals with mental health conditions compared with the general population. Tobacco harm reduction (THR) in the form of replacing cigarettes for electronic cigarettes (ECs) is an alternative approach which may prove useful for these smokers who find it difficult to quit. Exploring how mental health professionals' (MHPs) perceive ECs, and how these influence decision making regarding their use in clinical settings is essential to determine the feasibility of incorporating ECs into the treatment pathway.

METHODS

We conducted six focus groups between March and August 2017. A total of 39 MHPs were recruited from mental healthcare services in England. Discussions were guided by a semi-structured guide, and responses were recorded, transcribed and coded using thematic framework analysis.

RESULTS

MHPs generally adopt a risk-averse approach when judging the safety and suitability of ECs. Risk-aversion was influenced by perceived obscurity surrounding ECs and THR, as well as high exposure to adverse and unreliable information regarding ECs, and perceived analogies between ECs and conventional cigarettes. Some MHPs adopt a pragmatic approach when making decisions based on THR and EC use in daily practice by considering the context of treatment and patient circumstances. However, this is often accompanied by a high degree of caution and misconceptions which limits the potential benefit this intervention could have in mental healthcare settings.

CONCLUSION

Improved dissemination of national guidance and scientific literature regarding THR and ECs is essential in mental healthcare to eliminate misconceptions and better inform MHPs evidence-based decision-making practices.

A Combination of Factors Related to Smoking Behavior, Attractive Product Characteristics, and Socio-Cognitive Factors are Important to Distinguish a Dual User from an Exclusive E-Cigarette User

Although total cessation of nicotine and tobacco products would be most beneficial to improve public health, exclusive e-cigarette use has potential health benefits for smokers compared to cigarette smoking. This study investigated differences between dual users and exclusive e-cigarette users provide information to optimize health communication about smoking and vaping. A cross-sectional survey (n = 116) among 80 current, adult dual users and 36 current, adult-exclusive e-cigarette users was conducted in the Netherlands. The questionnaire assessed four clusters of factors: (1) Past and current smoking and vaping behavior, (2) product characteristics used, (3) attractiveness and reasons related to cigarettes and e-cigarettes, and (4) socio-cognitive factors regarding smoking, vaping, and not smoking or vaping. We used random forest-a machine learning algorithm-to identify distinguishing features between dual users and e-cigarette users. We are able to discern a dual user from an exclusive e-cigarette user with 86.2% accuracy based on seven factors: Social ties with other smokers, quantity of tobacco cigarettes smoked in the past (e-cigarette users) or currently (dual users), self-efficacy to not vape and smoke, unattractiveness of cigarettes, attitude towards e-cigarettes, barriers: accessibility of e-cigarettes, and intention to quit vaping (A). This combination of features provides information on how to improve health communication about smoking and vaping.

Indicators of cigarette smoking dependence and relapse in former smokers who vape compared with those who do not: findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey

BACKGROUND AND AIMS

It has been proposed that many smokers switch to vaping because their nicotine addiction makes this their only viable route out of smoking. We compared indicators of prior and current cigarette smoking dependence and of relapse in former smokers who were daily users of nicotine vaping products ('vapers') or who were not vaping at the time of survey ('non-vapers').

DESIGN

Cross-sectional survey-based comparison between vaping and non-vaping former smokers, including a weighted logistic regression of vaping status onto predictor variables, adjusting for covariates specified below.

SETTING

United States, Canada, Australia and England.

PARTICIPANTS

A total of 1070 people aged 18+ years from the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping Wave 1 Survey who reported having ever been daily smokers but who stopped less than 2 years ago and who were currently vapers or non-vapers.

MEASUREMENTS

Dependent variable was current vaping status. Predictor variables were self-reported: (1) smoking within 5 minutes of waking and usual daily cigarette consumption, both assessed retrospectively; (2) current perceived addiction to smoking, urges to smoke and confidence in staying quit. Covariates: country, sample sources, sex, age group, ethnicity, income, education, current nicotine replacement therapy use and time since quitting.

FINDINGS

Vapers were more likely than non-vapers to report: (1) having smoked within 5 minutes of waking [34.3 versus 15.9%, adjusted odds ratio (aOR) = 3.74, 95% confidence interval (CI) = 1.99, 7.03), χ2  = 16.92, P < 0.001]; having smoked > 10 cigarettes/day (74.4 versus 47.2%, aOR = 4.39, 95% CI = 2.22, 8.68), χ2  = 18.18, P < 0.001); (2) perceiving themselves to be still very addicted to smoking (41.3 versus 26.2%, aOR = 2.89, 95% CI = 1.58, 5.30, χ2  = 11.87, P < 0.001) and feeling extremely confident about staying quit (62.1 versus 36.6%, aOR = 3.22, 95% CI = 1.86, 5.59, χ2  = 17.36, P < 0.001). Vapers were not more likely to report any urges to smoke than non-vapers (27.7 versus 38.8%, aOR = 0.86, 95% CI = 0.44, 1.65, χ2  = 0.21, P = 0.643).

CONCLUSIONS

While former smokers who currently vape nicotine daily report higher levels of cigarette smoking dependence pre- and post-cessation compared with former smokers who are current non-vapers, they report greater confidence in staying quit and similar strength of urges to smoke.

Young people's perspectives of e-cigarette use in the home

There is concern that the emergence of e-cigarettes could result in an increase in young people's intake of, and exposure to, nicotine. This UK study used friendship group interviews to elicit the perspectives of young people from socioeconomically contrasting backgrounds regarding e-cigarettes. Young people from both advantaged and disadvantaged backgrounds described similar e-cigarette practices in the home environment, and, for both health and sensory reasons, viewed these as preferable to tobacco smoking. Space-related practices of adult e-cigarette use in the home were revealed to be more malleable than those of tobacco use. Results also highlighted that e-cigarettes offered young people new opportunities for nicotine consumption in the home. Methods of storing e-cigarettes in domestic spaces posed safety risks to younger children and easy access to e-cigarettes for others.

Are Electronic Cigarettes an Effective Aid to Smoking Cessation or Reduction Among Vulnerable Groups? A Systematic Review of Quantitative and Qualitative Evidence

INTRODUCTION

Smoking prevalence remains high in some vulnerable groups, including those who misuse substances, have a mental illness, are homeless, or are involved with the criminal justice system. E-cigarette use is increasing and may support smoking cessation/reduction.

METHODS

Systematic review of quantitative and qualitative data on the effectiveness of e-cigarettes for smoking cessation/reduction among vulnerable groups. Databases searched were MEDLINE, EMBASE, PsychINFO, CINAHL, ASSIA, ProQuest Dissertations and Theses, and Open Grey. Narrative synthesis of quantitative data and thematic synthesis of qualitative data.

RESULTS

2628 records and 46 full texts were screened; 9 studies were identified for inclusion. Due to low quality of evidence, it is uncertain whether e-cigarettes are effective for smoking cessation in vulnerable populations. A moderate quality study suggested that e-cigarettes were as effective as nicotine replacement therapy. Four studies suggested significant smoking reduction; however, three were uncontrolled and had sample sizes below 30. A prospective cohort study found no differences between e-cigarette users and nonusers. No significant adverse events and minimal side effects were identified. Qualitative thematic synthesis revealed barriers and facilitators associated with each component of the COM-B (capability, opportunity, motivation, and behavior) model, including practical barriers; perceptions of effectiveness for cessation/reduction; design features contributing to automatic and reflective motivation; smoking bans facilitating practical opportunity; and social connectedness increasing social opportunity.

CONCLUSION

Further research is needed to identify the most appropriate device types for practicality and safety, level of support required in e-cigarette interventions, and to compare e-cigarettes with current best practice smoking cessation support among vulnerable groups.

IMPLICATIONS

Smoking prevalence among people with mental illness, substance misuse, homelessness, or criminal justice system involvement remains high. E-cigarettes could support cessation. This systematic review found limited quantitative evidence assessing effectiveness. No serious adverse events were identified. Qualitative thematic synthesis revealed barriers and facilitators mapping to each component of the COM-B (capability, opportunity, motivation, and behavior) model, including practical barriers; perceived effectiveness; design features contributing to automatic and reflective motivation; smoking bans facilitating practical opportunity; and social connectedness increasing social opportunity. Further research should consider appropriate devices for practicality and safety, concurrent support, and comparison with best practice smoking cessation support.

A Deliberate Choice? Exploring the Decision to Switch from Cigarettes to E-Cigarettes

E-cigarettes are increasingly popular among both cigarette smokers and non-users. Although smoking cessation yields the most individual and population health benefits, switching to exclusive e-cigarette use offers some individual health benefits for cigarette smokers. However, e-cigarette use is not harmless, and its use among non-cigarette smokers should be prevented. Our study aims to explore the decision-making process about e-cigarettes among an e-cigarette users, cigarette smokers, and non-users. We conducted 12 semi-structured focus group interviews with e-cigarette users, cigarette smokers, and non-users. We performed a thematic analysis of the interview transcripts. First, knowledge reported by e-cigarette users was mainly based on other users’ experiences. Second, cigarette smokers and non-users were more negative towards e-cigarettes than e-cigarette users. Third, e-cigarette users considered switching from cigarette smoking to e-cigarette use by deliberating relevant information, and weighing up the benefits and disadvantages of e-cigarette use versus smoking. Additionally, important factors in the decision-making process were a perception of risks and benefits of e-cigarettes compared to cigarettes, a supportive social environment about e-cigarette use, and trust in information offered about the risks and benefits of e-cigarettes. Our findings provide insight into what we can learn from the conscious decision-making process of e-cigarette users who switched from cigarettes to e-cigarettes. This information can be considered to develop targeted communications strategies to stimulate a conscious decision-making process, these may highlight benefits of switching to e-cigarettes for cigarette smokers, discussing the risks of smoking, and correcting misperceptions about the perceived risks and benefits of e-cigarette use.

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.

Support for e-cigarette regulations among Australian young adults

BACKGROUND

Surveying support for various regulatory options relating to e-cigarettes can assist policymakers to identify those that have broad support and are therefore likely to be easier to implement. However, data on support for potential e-cigarette regulations in Australia are limited. To inform regulatory efforts, the present study assessed attitudes to the regulation of e-cigarettes among Australian young adults, the most prevalent users of e-cigarettes and therefore the most likely population segment to be affected by e-cigarette regulations.

METHODS

A total of 1116 Australians aged 18 to 25 years (59% female) completed an online survey where they were presented with various statements relating to the regulation of e-cigarettes and asked to report on the extent to which they agreed or disagreed with each. Statements presented either a restrictive or non-restrictive approach to e-cigarette regulation.

RESULTS

Across all statements, 10-22% of respondents responded "don't know" while 23-35% neither agreed nor disagreed, indicating general ambivalence. There was a moderate level of support (33-37%) for regulating e-cigarette sales/use and treating e-cigarettes like tobacco products. Only 20% of respondents were in favour of allowing the use of e-cigarettes in smoke-free areas. Smokers, e-cigarette users, and those who did not believe in the harms associated with e-cigarettes were typically less likely than other respondents to support restrictive approaches.

CONCLUSIONS

The young Australian adults surveyed were somewhat supportive of restrictions around the sale and use of e-cigarettes, but generally opposed outright bans and any need for a prescription from a medical practitioner. Increasing awareness of the harms associated with the use of e-cigarettes represents a potential strategy to gaining regulatory support.

Are smokers who are regularly exposed to e-cigarette use by others more or less motivated to stop or to make a quit attempt? A cross-sectional and longitudinal survey

BACKGROUND

Concerns have been raised that observing other people using e-cigarettes may undermine motivation to quit by renormalising smoking. This study aimed to explore associations between regular exposure to other people's e-cigarette use and motivation to stop smoking and quit attempts in smokers.

METHODS

Data were from 12,787 smokers in England who participated in the Smoking Toolkit Study between November 2014 and May 2018. At baseline, respondents were asked whether anyone other than themselves regularly used an e-cigarette in their presence, whether they had made a quit attempt in the past year and how motivated they were to stop. Data at 6-month follow-up were available for 1580 respondents, who reported on whether they had attempted to quit in the past 6 months.

RESULTS

Smokers who reported regular exposure to e-cigarette use by others were more likely than those who did not to have tried to stop smoking in the past year (32.3% vs. 26.8%; unadjusted RR 1.21, 95% CI 1.11-1.31) and have high motivation to quit (16.6% vs. 14.2%; unadjusted RR 1.17, 95% CI 1.05-1.30) but were not significantly more or less likely to make a quit attempt over the subsequent 6 months (34.4% vs. 31.3%; unadjusted RR 1.10, 95% CI 0.88-1.38). In models that adjusted for participants' own current e-cigarette use and unadjusted and adjusted models excluding current e-cigarette users from the sample, there were no significant associations between exposure to e-cigarette use by others and past quit attempts (RR 0.97-1.00), high current motivation to quit (RR 0.97-1.00) or prospective quit attempts (RR 0.94-1.12). In contrast, exposure to use of cigarettes was associated with low motivation to quit even after adjustment (RR 0.89) but not with quit attempts. Participants' own use of e-cigarette was strongly associated with high motivation to quit (RR 1.95) and past quit attempts (RR 2.14) and appeared to account for the bivariate associations with reported exposure to e-cigarettes.

CONCLUSION

Smokers who report regular exposure to other people using e-cigarettes are more likely to report past quit attempts and high current motivation to quit, but there does not appear to be an independent association with motivation or quit attempts after adjustment for their own current use of e-cigarettes. In contrast, reported exposure to other people using cigarettes was independently and negatively associated with high motivation.

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.

Perceptions of harm from electronic-cigarette use among a sample of US Navy personnel

INTRODUCTION

Scant information exists on the perceptions and behaviors surrounding electronic cigarette (EC) use in the U.S. military. The Health Belief Model (HBM) enables factors influencing behavior adoption to be assessed. Utilizing this model, this study explored five EC-related perceptions among a sample of active-duty Navy personnel.

METHODS

Participants were invited to complete a questionnaire involving EC use and perceptions. Demographics were reported and perceptions assessed using multiple choice and answer questions. Analyses included benefit and harm ratios and non-parametric tests.

RESULTS

Among the 977 participants, 29.7% tried ECs, 9.5% were current users and 3.8% were dual users. A large proportion of the population believed that ECs were less harmful than cigarettes, the safest alternative to cigarettes, accepted by non-users, and allowed in areas where cigarettes are prohibited. On the other hand, the majority believed that ECs did not make the user look cool or fit in and were not safe to use around children. EC users, cigarette smokers, men, those under 30 years of age, and those with less than a bachelor degree were more likely to have positive beliefs and perceptions about EC use.

CONCLUSIONS

The majority of the population studied has negative perceptions and beliefs about EC use. Several groups have beliefs that highlight vulnerabilities to EC experimentation and use. The findings illustrated concepts related to cessation and behavior adoption, harm-to-self and second-hand vapor, and smoke-free zones. These findings may help to identify motivations for experimentation and use, as well as to direct future EC intervention and prevention 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.

Electronic Cigarette Use among Current Smokers: A Pilot Qualitative Study

OBJECTIVE

This pilot study explored psychosocial influences of e-cigarette use among dual users.

METHODS

Two focus groups among adult current smokers who had ever used e-cigarettes were conducted in Georgia. Discussions were audio-recorded. Principles of grounded theory and thematic analysis were employed.

RESULTS

Reasons for initial use included curiosity and social influence. Themes related to regular use included enjoyment of sensory experiences and perception of reduced harm. Nicotine craving, social image, and convenience were reasons for initial and regular dual use. Two patterns of use emerged - (1) using e-cigarettes to supplement combustible cigarettes; and (2) to replace combustible cigarettes.

CONCLUSIONS

Reasons for dual use were related to nicotine dependence, social influence, product appeal, and perception of reduced harm. Understanding contextual nuances of dual use can inform policy and communication.