User pathways of e-cigarette use to support long term tobacco smoking relapse prevention: a qualitative analysis

Introduction

In the United Kingdom (UK), vaping nicotine is mainly confined to smokers or ex-smokers [1], and e-cigarettes are the most popular consumer choice to assist quitting tobacco smoking [2]. There is support of vaping for smoking cessation by Public Health England [3] and health advisory bodies [1, 4-6], and clear regulation permitting use of e-cigarettes by adult smokers [7] but limiting advertising [8] and restricting access for young people and never smokers [9]. This is in contrast to other countries, where the regulatory environment has been less clear, and recent policy has taken a stricter prohibitory position [10], with potential consequential outcomes for smoking relapse prevention. Although long-term e-cigarette use as a substitute to tobacco smoking remains controversial due to unknown health harms, there is strong medical consensus that stopping smoking for good is the most efficacious health behaviour change that smokers can make in avoiding future cancer risk [11].

Our previous cross sectional data, from wave 1 of this study, demonstrated in-depth views and experiences of switching from tobacco smoking to e-cigarette use, suggesting that e-cigarette use might be a viable long term substitute for smoking, through meeting physical, psychological, cultural, social, and identity-related aspects of tobacco addiction that some ex-smokers struggle to overcome [12]. This exploratory work also suggested that ‘lapses’ in the context of switching need not result in full blown smoking ‘relapse’ [13]. Longitudinal analysis of survey data from other sources has suggested that e-cigarette characteristics and behaviours impact on relapse status [14]. In this study, we report longitudinal qualitative follow-up data (wave 2) to establish detailed trajectories over time.

Theoretically, our focus is integration of behaviour change maintenance, across psychological and social influences. Kwasnicka et al. [15] provide an organising structure, with themes related to behaviour maintenance motives, self-regulation, resources, habits, environmental, and social influences; a theoretical approach applied in previous studies of smoking trajectories [16]. We foreground a ‘pathways’ narrative approach to understanding behaviour over the life course. This assumes a human drive to maintain congruence in identity self-concept over time, externally observable via behaviour [17].

In this article, we sought to understand user patterns of e-cigarette use and long-term smoking abstinence by exploring the research question: ‘what is the continued experience of e-cigarette use over time in the context of either tobacco smoking abstinence or relapse?’ Qualitative longitudinal data can illuminate nuances in individual trajectories though switching to e-cigarette use. This might inform understanding of long-term patterns of behaviour that best support complete tobacco cessation.

Methodology

Results

Participants' age at follow up interview ranged from 22 to 71 (mean = 42, SD 14.317). Baseline characteristics are reported elsewhere [12] but also summarised in Table 1, grouped by the three trajectories reported below. At T1, 28 participants were using e-cigarettes and abstinent from tobacco (16 had reported lapses), six participants had relapsed (five ‘dual-using’ both tobacco and e-cigarettes), and three were no longer either using e-cigarettes or smoking tobacco. At T2 follow-up, patterns of use remained reasonably consistent; 3/28 (9.7%) who were abstinent at T1 had relapsed by T2. Overall 8/37 had relapsed since trying to quit smoking by using e-cigarettes (21.6%) (Fig. 1).

We identified three trajectories of long-term e-cigarette use: maintainers, abstainers, and relapsers (Table 2).

Discussion

Using UK qualitative longitudinal data, we illuminate three key e-cigarette using pathways—the ‘maintainer’ pathway (e-cigarette use and not smoking), the ‘abstainer’ pathway (neither smoking nor using e-cigarettes), and the ‘relapser’ pathway (dual-using, or relapsed back to tobacco smoking only). We interrogated the trajectories to draw out individually influenced motives and habits, resources, environmental and social influences, mapping to Kwasnicka et al.’s integrated theory of behaviour change maintenance [15]. Through each of the pathways, individual experiences with using nicotine are critical, but these are heavily influenced by social factors, such as a supportive vaping context for the maintainers, or dislike of the ‘vaping culture’ expressed by some in the relapser group. Treating the data as narratives, we are able to understand the process of vaping over time and patterns of use that link through accounts of identity to tobacco smoking or quitting. For many, particularly perhaps the ‘abstainer’ group who have moved to quitting both e-cigarettes and tobacco, a natural progression towards abstinence is apparent, that may be likened to a ‘maturing out’ effect previously reported in other addictive behaviours [19]. This implies that smoking cessation by using e-cigarettes may be a process that evolves over time, as individuals disengage from a smoker identity, and might best be regarded as a positive step towards smoking cessation, rather than an instant switch [20-22]. Indeed, the gradual ‘slide’ toward abstinence that the data supports, and the behavioural processes of occasional tobacco lapses that serve apparently to negatively reinforce ongoing tobacco abstinence, suggest that a period of time allowing experimentation and adaptation of behaviour, integrating the new non-smoker identity, is necessary to fully switch from tobacco smoking to e-cigarette use. Previous studies of smoking cessation have similarly demonstrated how quitting can include elements of both spontaneity and preparation, that are especially pertinent in the context of e-cigarette use [23]. For the largest ‘maintainer’ group, continued e-cigarette use may be protective against smoking relapse, a positive long term-maintained behaviour, and is accepted as an integrated part of identity.

An alternative hypothesis, that using e-cigarettes may leave people vulnerable to smoking relapse through maintaining nicotine addiction [24], is a prevalent concern in other policy contexts. This view is contradicted by recent cohort data [25]. In our qualitative longitudinal data, we also observe some long-term e-cigarette users reporting experiencing a natural and easy reduction of dependence through reducing nicotine strengths over time, a reported reduction of cravings and tobacco lapse behaviour, and a belief that addiction to nicotine has waned.

The ‘maintainers’ may continue to use e-cigarettes long-term. They experience e-cigarettes as personally satisfying and enjoyable, and many also enjoy the social and identity related aspects of e-cigarette use, in a similar way to that identified by previous studies where e-cigarette use is presented as a positive social practice that opens up time and space [26]. Although evidence consensus reviews suggest that e-cigarette use is much less harmful than tobacco smoking [27, 28], there is, as yet, no public health consensus on the health consequences of long-term use. Others within our sample, the ‘abstainers’, had moved to quitting both tobacco and e-cigarettes. For some people, continuing to use nicotine is neither desirable nor congruent with identity, and conceivably, this may be a pathway that others may choose to take over time. At present, there is no evidence-based advice on how to support people to stop using e-cigarettes, if that is their choice. There is a need for such advice, particularly in supporting people to avoid any possibility of relapsing back to tobacco smoking. Our data preliminarily suggest that strategies such as gradual weaning towards lower nicotine strength e-liquid may be successful for some people. Conversely, to remain on a pathway toward full tobacco abstinence, the qualitative data suggest a need to support e-cigarette users to switch to higher nicotine strength e-liquid during times of stress, if necessary, to avoid cravings and risking smoking relapse.

Most of the relapsers and abstainers shared similar attitudes over time that contrasted with the maintainers: that they should only use e-cigarettes as a temporary measure, they were uncomfortable with long-term nicotine use, and were suspicious of e-cigarette safety. The maintainers, conversely, were comfortable with nicotine use. They enjoyed e-cigarette use as a pastime and felt invested with a ‘vaper’ identity. They also saw e-cigarettes as much less harmful as smoking and felt supported by their social groups. Relapsers differed to both the abstainers and maintainers in that they were less motivated to quit—they enjoyed cigarette smoking, maintained a belief that cigarettes were necessary to cope with stress, and held more negative views about vape shops and vape culture that other groups saw conversely as a source of support. They were also of a younger age, on average.

Our findings are limited in that they are drawn from a small qualitative sample. Although the initial purposive sample reflected the general population of quitters, those from ethnic minorities and low socioeconomic groups are not well represented. It is also likely that the sample is skewed toward those most motivated to maintain smoking abstinence and most willing to share their experiences. However, a strength is the in-depth perspectives gleaned, allowing detailed exploration of individual trajectories of e-cigarette use behaviour over time. This provides robust experiential data and allows us to illuminate major patterns of use, suggest areas of need, and hypothesise support that may be necessary for long term smoking cessation.

To promote tobacco smoking relapse prevention, our findings suggest that supporting continued e-cigarette use, as reported by the ‘maintainer’ group, might be beneficial. E-cigarette users require frequently updated evidence-based advice on the relative safety of e-cigarettes in comparison to tobacco smoking. For dual users or those who occasionally lapse to tobacco, there is a need to tackle beliefs about dependence on tobacco and offer alternative strategies for triggers such as stress. For those who struggle to find a satisfying and effective e-cigarette set-up, there is a great need for support, perhaps from peers, who are a valued source of advice [29, 30]. Particularly, there is a need for information about increasing or reducing nicotine strengths, to prevent cravings and cope with stressors, and advice on using different flavours to suit preferences and aid sustained cessation [31]. Those who eventually wish to quit e-cigarettes need evidence-based information about effective ways to do this, without increasing vulnerability to tobacco relapse.

In delineating three major pathways through e-cigarette use, our data demonstrate a clear role of e-cigarettes in smoking relapse prevention in the UK policy context. This suggests that policies supportive of vaping could be adopted by other jurisdictions concerned with smoking relapse. Once quit smoking, the majority pattern apparent in our data is a move towards exclusive, ongoing, e-cigarette use. For some, there is a move completely away from both smoking and e-cigarettes. For a minority, there are continued patterns of dual use or relapse back to tobacco smoking. Future research might focus on younger people who may be less motivated to ‘mature out’ of dual use or tobacco smoking behaviour. Health efforts need to prioritise intervention with this group, through targeting individual level beliefs and physical dependence needs, social level support, and cultural level reinforcement of reduced harm alternatives that might support complete smoking cessation.

Declaration of interests

C.N., E.W., and R.H. declare no competing interests. L.D. has provided consultancy for the pharmaceutical industry relating to the development of smoking cessation products.

Author contributions

Caitlin Notley: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization. Emma Ward: Formal analysis; methodology; project administration. Lynne Dawkins: Conceptualization; funding acquisition; methodology; project administration. Richard Holland: Conceptualization; funding acquisition; methodology; supervision.