Responsibility,normalisation and negotiations of harm: E-cigarette users' opinions and experiences of vaping around children

BackgroundConcern about youth uptake of vaping is widespread. Regulation and education campaigns aim to protect children from initiating use, yet it is likely that children will be primarily influenced by the behaviour of people in their immediate environment. This is the first known study exploring e-cigarette users’ views and reported experiences of vaping around children.MethodsFollowing informed consent, semi-structured qualitative interviews were conducted with 40 adults who had attempted to give up smoking by vaping. Participants were recruited from England as part of a wider study into e-cigarette use trajectories and smoking relapse (ECtra study). Data were extracted from 28 interviews where participants had spontaneously discussed vaping around children. Extracted data were analysed thematically and situated in previous analysis of vaping identity which distinguished between recreational and medicinal vapers.ResultsVaping behaviour around children was in part a habituated replication of smoking norms but also guided by broad vaping identity; recreational users were more permissive and medicinal users more secretive. Vaping in the home appeared to be determined by caregivers’ need to reconcile vaping behaviour so that it was congruent with parental identity as a responsible caregiver. Participant perspectives reflected existing moral discourses applied to e-cigarettes around the use of “harm reduction for smokers” and “potential for youth harm”.ConclusionVaping is likely to be role modelled within the community and home despite attempts by e-cigarette users to conceal the behaviour. The ambivalent contextualisation of e-cigarettes means that e-cigarette users may lack a clear narrative to draw on when discussing vaping with children. Public health guidance for vaping around children could be helpful, but to be most effective, should take into consideration users’ vaping identity.     

Vapers and vaping: E-cigarettes users views of vaping and smoking

The use of electronic cigarettes has increased markedly in recent years, however, as the popularity of e-cigarettes has increased, so has the controversy associated with their use. In this paper we report the views of a small sample of e-cigarette users focussing on the circumstances in which individuals began vaping, their reasons for continuing vaping, their perceptions of the relative harm of vaping compared to smoking, and their views as to whether their use of e-cigarettes had increased their likelihood of smoking. In total we interviewed 50 vapers aged between 16 and 26. Typically, vapers explained their continued use of e-cigarettes in terms of the reduced harm compared to smoking, the lack of an offensive smell, the appeal of different flavours, the greater range of settings in which e-cigarettes could be used, and the reduced stigma associated with their use. The sample of interviewees were evenly split with regard to the perceived justification (or not) for banning vaping in public. Finally, we make the case that it is important to base policy and regulation of e-cigarettes on both robust epidemiological data on the impact of these devices as well as more qualitative, ethnographic, information from users themselves.     

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

BackgroundThe aim of this study was to identify and differentiate socially shared accounts of e-cigarette use (vaping) using Q-methodology, combining factor analysis with qualitative comments.MethodsSeventy statements on e-cigarettes, drawn from media, academic and online discussions, were sorted by participants along a continuum of agreement/disagreement, commenting on strongly ranked items. Each participant thus created their own ‘account’ of their vaping. A by-person correlation matrix of the sorts was conducted, then factor analysed, to identify similar accounts (p < 0.01). Fifty-five UK vapers participated by post, 55% male, mean age of 46, 84% only vaping/16% vaping and smoking, 95% vaping daily.ResultsThree accounts of e-cigarettes were identified. The first two were associated with having quit smoking; the third with ongoing tobacco smoking and vaping. In Factor One, ‘Vaping as Pleasure’, vaping was characterized as enjoyable, with long-term use envisaged and a medical model of vaping rejected. Factor One participants also held a strong vaping identity and were politically motivated to maintain the rights of adults to vape. In Factor Two, ‘Vaping as Medical Treatment’, vaping was understood as a pragmatic choice about how to medicate one’s smoking addiction, with the aim being to treat and ultimately reduce nicotine dependence. In Factor Three, ‘Ambivalent E-Cigarette Use’, participants reported fewer benefits and harboured more negative beliefs about e-cigarettes; they also strongly rejected a vaper identity, having no interest in online forums or being labelled a ‘vaper’ themselves.ConclusionThe UK e-cigarette users in this sample were not a homogeneous group; differing in their beliefs, motivations for use, identity and political interest. In particular they diverged on whether they accepted a medicalized account of vaping and identified as a vaper. Public health messages targeted to one group of e-cigarette users may not resonate with others.     

青少年电子烟使用特点与戒烟效果研究进展

以传统香烟替代品出现的电子烟在广告宣传及成年人的榜样作用下,因其迷人的外表、多样的口味、电子烟"无害"的信念、有助于戒烟以及容易获得等因素在青少年中呈流行趋势.近来的研究发现,宣称"无害"的电子烟不仅损害青少年的生理健康与神经系统的发育,增加了不健康行为发生的风险,还存在"门户效应",成为青少年吸食传统香烟的桥梁,甚至...     

Perceptions about e-cigarette flavors: a qualitative investigation of young adult cigarette smokers who use e-cigarettes

Background: Although in recent years, an increased number of young adult smokers have used flavored e-cigarettes, little research has been conducted to explore young adult smokers’ perceptions about e-cigarette flavors.

Methods: This study used qualitative methods to examine young adult smokers’ perceptions towards e-cigarette flavors, their intentions of using e-cigarettes given a flavor ban, and their perceived role of e-cigarette flavors in their smoking behaviors. We conducted in-depth, semi-structured interviews to explore these themes among a purposive sample of 25 young adult smokers in the U.S. (aged 18–34) who had used e-cigarettes to reduce cigarette smoking. Thematic content analysis was employed to assess the qualitative data.

Results: Most participants reported enjoying e-cigarettes with fruit, candy, dessert or menthol/mint flavors and valued having a wide selection of flavors. Most participants reported that they would likely quit or significantly reduce e-cigarette use if e-cigarette flavors were banned. Participants had little knowledge of the nicotine concentration in their e-cigarettes or the harm associated with the use of e-cigarette flavorings. Additionally, participants perceived e-cigarette flavorings as helpful in cutting down smoking by allowing for increased e-cigarette use frequency and duration.

Conclusion: Participants indicated positive perceptions towards e-cigarette flavors and considered the role of e-cigarette flavors to be important in cutting down on cigarettes. Banning or restricting flavored e-cigarettes may discourage participants from using e-cigarettes for smoking cessation. The lack of knowledge about flavored e-cigarettes’ harm and risks, together with the escalated consumption of flavored e-cigarettes, are causes for concern and warrant further attention.     

‘Vaping and fidget-spinners’: A qualitative,longitudinal study of e-cigarettes in adolescence

BackgroundWe see the contours of a cigarette-free adolescent cohort in Norway. Simultaneously, increasing use of vaping devices among adolescents internationally, and in the US in particular, has evoked fear of a new nicotine-addicted generation. This longitudinal study explores the vaping phenomenon in a context where nicotine e-liquid is still prohibited.MethodsData are from longitudinal, qualitative interviews with a sizable sample of 12-17 year olds (118 8^th graders from 6 schools/classes at baseline). Four follow-ups were conducted from 2015 to 2019 (a total of 50 semi-structured group and 175 individual interviews). The interviews were coded using HyperResearch software and thematically analysed in the light of actor network and interaction ritual theory.ResultsGradual and collective shifts in vaping practices and in the symbolic meaning of vaping were observed in three phases. First, in 8^th grade, few had tried to vape, even if several were curious about this novel invention, practice and the available flavours. Second, after 9^th grade, one in three reported personal use. They emphasised harmlessness, coolness, performance and accessibility online. However, by the end of middle school, a third phase became visible; vaping had lost status and was described as ‘childish’ and unpopular. Interviewees repeated the lack of relevance in high school, comparing e-cigarettes with the fidget-spinner and reserving vaping for kids and addicted adult smokers. The analysis displays a systematic pattern in which adolescents account for vaping as a time-limited trend.ConclusionE-cigarettes were devalued from novelty and transgression to childish and uninteresting within the same sample over a four-year period. In conclusion, e-cigarettes in the sample represented fashionable experimentation rather than steady user patterns.     

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

BackgroundThe 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.MethodsThe 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.ResultsMost 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.ConclusionsUsers 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.     

Measuring perceptions related to e-cigarettes: Important principles and next steps to enhance study validity

Measuring perceptions associated with e-cigarette use can provide valuable information to help explain why youth and adults initiate and continue to use e-cigarettes. However, given the complexity of e-cigarette devices and their continuing evolution, measures of perceptions of this product have varied greatly. Our goal, as members of the working group on e-cigarette measurement within the Tobacco Centers of Regulatory Science (TCORS) network, is to provide guidance to researchers developing surveys concerning e-cigarette perceptions. We surveyed the 14 TCORS sites and received and reviewed 371 e-cigarette perception items from seven sites. We categorized the items based on types of perceptions asked, and identified measurement approaches that could enhance data validity and approaches that researchers may consider avoiding. The committee provides suggestions in four areas: (1) perceptions of benefits, (2) harm perceptions, (3) addiction perceptions, and (4) perceptions of social norms. Across these 4 areas, the most appropriate way to assess e-cigarette perceptions depends largely on study aims. The type and number of items used to examine e-cigarette perceptions will also vary depending on respondents' e-cigarette experience (i.e., user vs. non-user), level of experience (e.g., experimental vs. established), type of e-cigarette device (e.g., cig-a-like, mod), and age. Continuous formative work is critical to adequately capture perceptions in response to the rapidly changing e-cigarette landscape. Most important, it is imperative to consider the unique perceptual aspects of e-cigarettes, building on the conventional cigarette literature as appropriate, but not relying on existing conventional cigarette perception items without adjustment.     

Cognitive risk factors of electronic and combustible cigarette use in adolescents

IntroductionCognitive susceptibility to cigarette smoking has been demonstrated to predict future cigarette initiation in adolescents. Examining this construct prior to tobacco product initiation may provide useful information on the differential risk of individuals initiating cigarette vs. e-cigarette products. Additionally, examining how susceptibility and tobacco product use relate to perceived harm cognitions will increase understanding of risk predisposition among adolescents.MethodData were taken from a longitudinal study of middle school students (n = 1023; age = 12.1, 52.2% female, 72.1% white) in the Northeastern U.S. Likelihood of e-cigarette and cigarette ever-use in high school was examined as a function of a validated index of cigarette smoking susceptibility among tobacco naïve students in middle school. Prospective associations between cognitive susceptibility to smoking and subsequent perceived harm of e-cigarettes (assessed in high school), and cross-sectional associations between concurrent tobacco product ever-use status and perceived harm of e–cigarettes were examined.ResultsAdolescents classified as susceptible to cigarette smoking in middle school were more likely to initiate use of cigarettes (OR = 2.53) and e-cigarettes (OR = 1.95) as compared to adolescents classified as non-susceptible; cigarette smoking susceptibility did not differentially predict use of one product over the other. Adolescents endorsing e-cigarette use, reported significantly less perceived harm associated with e-cigarettes vs. cigarettes, while those who endorsed cigarette only or dual use did not.ConclusionOur data indicate that cognitive susceptibility to cigarette smoking may index a broad risk factor for using either cigarettes or e-cigarettes in the future, and is prospectively associated with perceived harm of e-cigarette use. Overall, those who used any tobacco product perceived e-cigarettes as less harmful when compared to abstainers. Individual facets of perceived harm (addiction potential and harm vs. cigarettes) differ between cigarette only users and e-cigarette users and may help to explain the choice to use one product vs. the other.ImplicationsThis is the first study to examine prospective associations between cognitive susceptibility to cigarette smoking, predating tobacco use, and subsequent likelihood of cigarette vs. e-cigarette initiation. This study demonstrates that initiation of either product is elevated among youth who are susceptible to smoking; thus susceptibility to smoking may serve as a useful marker of vulnerability to tobacco product use. Furthermore, this study provides novel information on the relationship between tobacco product onset and specific harm perceptions associated with e-cigarettes versus cigarettes among adolescents.     

The moderating effect of gender on the association between E-cigarette use and smoking status: A cross-sectional study

IntroductionThe novel features of e-cigarettes in the recent vaping boom are appealing to females. Given increasing concerns about using e-cigarettes among females, understanding the patterns of using e-cigarettes in females compared to males is critical. We investigate the moderating effect of gender on the association between ever vaping and smoking status and gender differences in reason for ever vaping and in having ever stopped smoking.MethodsWe used population data (n = 38,661) from the 2015, 2016, and 2017 Texas Behavioral Risk Factor Surveillance System (BRFSS) to examine a gender difference in ever vaping associated with smoking status. Additionally, we restricted the sample to current smokers who have ever vaped (n = 4733) to examine the association of gender with quitting smoking as reason for ever vaping and with having ever stopped smoking.ResultsWe found a significant association between ever vaping and gender (OR = 0.77, 95%CI = 0.65, 0.91). When smoking status was considered, female never-smokers had a significantly lower likelihood of ever vaping than male never-smokers (OR = 0.43, 95%CI = 0.27, 0.76). No significant gender difference was found in ever vaping to quit smoking (OR = 1.12, 95%CI = 0.73, 1.74) and having ever stopped smoking (OR = 1.41, 95%CI = 0.95, 2.10).ConclusionsThe findings of this study provide evidence of gender differences in vaping patterns. Female never-smokers are less likely than male never-smokers to experiment with e-cigarettes. However, there is no evidence of a gender difference in both ever vaping to quit smoking and having ever stopped smoking. Consistent monitoring of gender differences in using e-cigarettes and stratified policy approaches tailored for genders are necessary.     

A qualitative study of e-cigarette emergence and the potential for renormalisation of smoking in UK youth

BackgroundGrowth of e-cigarette use among smokers has raised concerns over uptake by non-smokers, particularly young people. Legislative changes aimed in part at reducing youth exposure to e-cigarettes include the EU Tobacco Products Directive (TPD). A core justification for such measures is the belief that e-cigarettes can lead to tobacco smoking through mechanisms of renormalisation including: mimicking and normalizing the act of smoking; increasing product acceptability via marketing; nicotine exposure. These mechanisms are here explored in relation to findings from qualitative research.MethodsThis paper reports results from twenty-one group interviews with 14–15 year olds in Wales, England and Scotland, conducted as part of an ongoing evaluation of the impact of the TPD on youth smoking and e-cigarette use. Interviews were conducted around the end of the transitional period for TPD implementation, and explored perceptions of e-cigarettes and tobacco, as well as similarities and differences between them.ResultsYoung people differentiated between tobacco and e-cigarettes, rejecting the term e-cigarette in favour of alternatives such as ‘vapes’. Experimental or occasional use was common and generally approved of where occurring within social activity with peers. However, regular use outside of this context was widely disapproved of, unless for the purpose of stopping smoking. Increased prevalence of e-cigarettes did not challenge strongly negative views of smoking or reduce perceived harms caused by it, with disapproval of smoking remaining high. Nicotine use was variable, with flavour a stronger driver for choice of e-liquid, and interest more generally.ConclusionThe extent to which participants differentiated between vaping and smoking, including styles and reasons for use in adults and young people; absence of marketing awareness; and continued strong disapproval of smoking provides limited support for some of the potential mechanisms through which e-cigarettes may renormalise smoking. However caution over nicotine exposure is still necessary.     

Alcohol Makes You Macho and Helps You Make Friends: The Role of Masculine Norms and Peer Pressure in Adolescent Boys’ and Girls’ Alcohol Use

Peer pressure and general conformity to adult norms have been found to be strongly associated with alcohol use among adolescents; however there is limited knowledge about the sociocultural factors that might influence this relationship. Theory and research suggest that masculine norms might directly and indirectly contribute to alcohol use through peer pressure and general conformity to adult norms. Whereas being male is typically identified as a risk factor for alcohol use, masculine norms provide greater specificity than sex alone in explaining why some boys drink more than others. There is growing evidence that girls who endorse masculine norms may be at heightened risk of engaging in risky behaviors including alcohol use. Data were provided by adolescents living in a rural area in the Northeastern United States and were collected in 2006. This study demonstrated that masculine norms were associated with peer pressure and general conformity and alcohol use for both adolescent girls (n = 124) and boys (n = 138), though the relationship between masculine norms and alcohol use was stronger for boys. The study's limitations are noted and theoretical and practical implications are discussed.     

Perceptions of the harm,addictiveness, and smoking cessation effectiveness of e-cigarettes among Australian young adults

An extensive body of evidence indicates that e-cigarette use is highest among young adults, prompting concerns about the potential renormalization of smoking behaviors in a population segment that is particularly vulnerable to tobacco smoking initiation. Increasing levels of e-cigarette use among young adults are likely a reflection of favorable beliefs about the benefits and risks associated with use, but research assessing perceptions of e-cigarettes in this population segment is limited. The aim of the present study was to assess young adults' perceptions of (i) the absolute and relative harm associated with e-cigarette use and (ii) the efficacy of these devices for smoking cessation. In a sample of 1116 Australian 18 to 25 year olds, three-quarters believed e-cigarettes have some level of harm (72%), just over half believed them to be addictive (57%), and substantial minorities reported that they did not know whether these products are harmful (20%) or addictive (34%). Two-fifths believed e-cigarettes are effective at helping people quit smoking (42%). Differences were observed by smoking status and e-cigarette user status on several variables, with a general trend of more positive perceptions towards e-cigarettes among smokers and users, particularly in relation to cessation efficacy. Results suggest that a substantial minority of young adults are unaware of the harms that may be associated with e-cigarettes, underscoring the importance of public health efforts that aim to provide accurate information about these devices.     

Impact of messages about scientific uncertainty on risk perceptions and intentions to use electronic vaping products

BackgroundThe science surrounding e-cigarettes and other electronic vaping products (EVPs) is rapidly evolving, and the health effects of vaping are unclear. Little research has explored how individuals respond to information acknowledging scientific uncertainty. The aim of the present study was to understand the impact of messages about scientific uncertainty regarding the health effects of vaping on risk perceptions and behavioral intentions.MethodsAdults in an online experiment (n = 2508) were randomly exposed to view either a control message (a short factual statement about EVPs) or an uncertainty message (the control message plus additional information describing why EVP-related research is limited or inconclusive). Participants rated the risks of vaping and their intentions to try or stop vaping.ResultsIndividuals who viewed the uncertainty message rated vaping as less risky than those who viewed the control message. Message exposure did not impact intentions to try vaping soon or intentions to stop vaping in the next 6 months.ConclusionsAcknowledging scientific uncertainty made EVP use seem less risky. Future research should explore possible drivers of this response, such as deeper message processing or emotional reactions. Researchers and practitioners designing public health campaigns about vaping might consider a cautious approach to presenting information about scientific uncertainty.