Understanding perceived addiction to and addictiveness of electronic cigarettes among electronic cigarette users: a cross-sectional analysis of the International Tobacco Control Smoking and Vaping (ITC 4CV) England Survey

BACKGROUND AND AIMS

The addictive potential of electronic cigarettes (e-cigarettes) remains to be fully understood. We identified patterns and correlates of perceived addiction to e-cigarettes and perceived addictiveness of e-cigarettes relative to tobacco cigarettes (relative addictiveness) in dual users as well as exclusive e-cigarette users.

DESIGN, SETTING AND PARTICIPANTS

Observational study using cross-sectional survey data from England (2016) from the International Tobacco Control Project (ITC) Four Country Smoking and Vaping (4CV) survey. The study comprised 832 current e-cigarette users who had been vaping for at least 4 months.

MEASUREMENTS

Perceived addiction to e-cigarettes and relative addictiveness of e-cigarettes were examined. Socio-demographic factors were age, gender and education; markers of addiction included urge to vape, time to first vape after waking and nicotine strength used; vaping and smoking characteristics included frequency and duration of e-cigarette use, intention to quit, adjustable power or temperature, enjoyment, satisfaction relative to tobacco cigarettes and tobacco cigarette smoking status.

FINDINGS

A total of 17% of participants reported feeling very addicted to e-cigarettes, while 40% considered e-cigarettes equally/more addictive than tobacco cigarettes. Those who felt very addicted had higher odds of regarding e-cigarettes as more addictive than tobacco cigarettes (odds ratio 3.4, 95% confidence interval 2.3-5.1). All markers of addiction, daily use and enjoyment were associated with higher perceived addiction, whereas time to first vape after waking, daily vaping and perceiving vaping as less satisfying than smoking were associated with relative addictiveness.

CONCLUSIONS

Markers of addiction to e-cigarettes appear to correspond with perceived addiction to e-cigarettes, suggesting that self-reported perceived addiction might serve as an indicator of addiction. Prevalence both of markers of addiction and perceived addiction were comparatively low overall, suggesting a limited but relevant addictive potential of e-cigarettes. Additionally, positive and negative reinforcement, reflected here by enjoyment and relative satisfaction, might play a role in e-cigarette addiction.

Using computer-based habit versus chess-based cognitive remediation training as add-on therapy to modify the imbalance between habitual behavior and cognitive control in tobacco use disorder: protocol of a randomized controlled, fMRI study

BACKGROUND

Although the vast majority of smokers are aware of the enormous preventable health hazards caused by smoking, only a small percentage of smokers manage to remain abstinent in the long term. One possible explanation for this discrepancy lies in the inflexibility of addictive behavior and associated disadvantageous decision-making. According to a dual-process theory of decision-making, two distinct decision systems can be identified. One slow deliberate system based on desirable expectations of outcome value described as goal-directed behavior and a fast reflexive system based on habitual instrumental behavior and driven by reinforcement experienced in the past. In the course of addiction development, an imbalance occurs between habitual behavior and goal-directed. The present study aims to investigate the modifiability of the balance between habitual and goal-directed behavior at the neurobiological and behavioral level in smokers using two different novel add-on therapies. We hypothesize that both interventions change the balance between goal-directed and habitual behavior, but by different mechanisms. Whereas a cognitive remediation treatment should directly improve cognitive control, in contrast an implicit priming task should affect the early processing and the emotional valence of smoking and smoking cues.

METHODS

We will conduct a randomized controlled study in treatment-seeking individuals with tobacco use disorder applying either chess-based cognitive remediation training (N = 30) or implicit computer-based habit-modifying training (N = 30) as add on therapy compared to the standard smoking cessation group therapy (N = 30) only. We will address neurobiological and neuropsychological correlates associated with craving, reward devaluation, cue reactivity and attentional bias. In addition, various effects of treatment and prediction of treatment outcome will be examined using behavioral and neural measures.

DISCUSSION

The present study will apply different examination methods such as functional magnetic resonance imaging, neuropsychological tests, and self-report before and after the interventions. This allows the identification of intervention-specific mechanisms and therefore potential neurobiology-based specific treatment targets for individuals with Tobacco Use Disorder.

TRIAL REGISTRATION

Registered at clinicaltrials.gov/ct2/show/NCT03764969 (05 December 2018).

Addictive Potential of e-Cigarettes as Reported in e-Cigarette Online Forums: Netnographic Analysis of Subjective Experiences

BACKGROUND

While e-cigarettes usually contain nicotine, their addictive potential is not yet fully understood. We hypothesized that if e-cigarettes are addictive, users will experience typical symptoms of addiction.

OBJECTIVE

The aim of our study was to investigate whether and how e-cigarette users report signs of addiction.

METHODS

We identified 3 large German-language e-cigarette online forums via a systematic Google search. Based on a netnographic approach, we used deductive content analysis to investigate relevant posts in these forums. Netnography has the advantage of limiting the social desirability bias that prevails in face-to-face research, such as focus groups. The data were coded according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria for tobacco use disorder, adapted for e-cigarettes. The DSM-5 criteria were used to portray a broad spectrum of possible experiences of addiction.

RESULTS

Overall, 5337 threads in 3 forums were screened, and 451 threads containing relevant information were included in the analysis. Users reported experiences consistent with the DSM-5 criteria, such as craving e-cigarettes, excessive time spent vaping, and health issues related to e-cigarette use. However, our analysis also showed that users reported the absence of typical tobacco use disorder criteria, such as successful attempts to reduce the nicotine dosage. For most themes, reports of their absence were more frequent than of their presence. The absence of perceived addiction was mostly reported in contrast to prior tobacco smoking.

CONCLUSIONS

This is the first study to use a netnographic approach to explore unfiltered self-reports of experiences of e-cigarette addiction by users in online forums. As hypothesized, some but not all users reported subjective experiences that corresponded to the criteria of tobacco use disorder as defined by the DSM-5. Nevertheless, subjective reports also indicated that many e-cigarette users felt in control of their behavior, especially in contrast to their prior use of tobacco cigarettes. The finding that some e-cigarette users subjectively experience addiction highlights the need for effective cessation programs to support users who experience their e-cigarette use as burdensome. This research can guide the refinement of instruments to assess e-cigarette addiction and guide cessation programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s40359-021-00682-8.

Understanding addiction in e-cigarette users – the EVAPE project

Background

Electronic cigarettes (e-cigarettes) are often advertised as a healthier option to combustible cigarettes and as smoking cessation aid. However, e-cigarettes are a growing health concern and their addictive potential remains to be fully understood. Within the EValuation of the Addictive Potential of E-cigarettes (EVAPE) project, we studied subjective and objective measures of addiction in relation to e-cigarette use.

Methods

This cross-sectional analysis was based on 832 participants of the first wave (2016) of England from the ITC Four Country Smoking and Vaping (4CV) Survey, who were using e-cigarettes daily or weekly for at least four months. Perceived addiction to e-cigarettes was categorised as very vs. not/somewhat addicted, and perceived addictiveness of e-cigarettes relative to combustible cigarettes as equally/more addictive vs. less addictive. Objective measures of addiction included urge to vape, time to first vape after waking, frequency of use, and used nicotine strength. We examined associations between these objective and subjective measures of addiction using multivariate logistic regression, adjusted for age, gender, education, and cigarette smoking.

Results

17.8% of participants reported feeling very addicted to e-cigarettes and 42.3% considered e-cigarettes equally/more addictive than combustible cigarettes. Those who felt very addicted had higher odds of regarding e-cigarettes as more addictive (OR 3.43 (95%-CI 2.29-5.19)). All objective measures of addiction were associated with higher perceived addiction, whereas only a shorter time to first vape was associated with perceived product addictiveness.

Conclusions

Subjective measures of addiction to e-cigarettes, in particular perceived addiction, correspond with objective measures. Understanding the addictive potential of e-cigarettes is the cornerstone for developing new strategies for prevention and treatment, and ultimately understanding their role from a public health perspective.

Key messages

The effects of nalmefene on the impulsive and reflective system in alcohol use disorder: A resting-state fMRI study

RATIONALE

Central aspects of alcohol use disorder (AUD) are the irresistible desire for alcohol and impaired control over its intake. According to the triadic neurocognitive model of addiction, this arises from aberrant functioning of different neural and cognitive systems: an impulsive system, a reflective system, and the abnormal dynamics between both systems based on an insular-dependent system.

OBJECTIVES

In this study, we examined the effects of a single dose of nalmefene on resting-state functional connectivity (rsFC) patterns within and between these addiction-related neural systems in AUD.

METHODS

Non-treatment seeking participants with AUD (N = 17; 19-66 years, 6 female) took part in a randomized, placebo-controlled, double-blind, crossover study and received either a single dose of 18 mg nalmefene or a placebo. Using seed-based correlation analyses on resting-state functional magnetic resonance imaging data, we examined the effects of nalmefene on key nodes related to the (1) impulsive system; (2) reflective system; (3) salience network; and (4) default mode network.

RESULTS

Under nalmefene, participants showed reduced rsFC between components of the impulsive system (Nucleus accumbens-putamen/pallidum/insula). Reduced rsFC was found between elements of the reflective system and impulsive system (orbitofrontal cortex-insula/putamen/pallidum), salience network (orbitofrontal cortex-insula/inferior frontal gyrus), and default mode network (lateral prefrontal cortex-precuneus/cuneus). Components of the salience network showed both increased (anterior cingulate cortex) and decreased (insular cortex) rsFC to elements of the reflective system.

CONCLUSION

A single dose of nalmefene impacts rsFC and alters the interaction between key nodes of addiction-related neural systems in non-treatment seeking participants with AUD. Nalmefene may normalize rsFC patterns by weakening the impulsive system while strengthening the reflective system.

TRIAL REGISTRATION

clinicaltrials.gov: NCT02372318.