Young adults and e-cigarettes: a qualitative exploration of awareness, experience and attitudes

12 Discussion

12.1 This study sought to explore the views and experiences of young adults in Scotland in relation to e-cigarettes. Its objectives were to find out what they know about them; what they feel they need to know about them; what they think about them; and their experiences of using them.

12.2 The study used a purposive sampling approach to include young adults in different socio-economic circumstances and those with different experiences of smoking, vaping and not smoking. However, the focus was mainly on young adults who smoke, or vape, or do both. This accounts for the high proportion of participants in this study who had experience of vaping.

What young adults know, and want to know, about e-cigarettes

12.3 There were high levels of awareness of e-cigarettes across all the focus groups, although less so among the groups of non-smokers. The use of e-cigarettes appeared to be relatively common in the family and social networks of the young adults who took part. This may relate partly to the socio-demographic characteristics of this group, and it may also relate to the urban focus of the research.

12.4 In terms of specific knowledge about e-cigarettes, this was more variable within the groups. Much of the information young adults had about e-cigarettes had been acquired through informal networks (family and friends who use the devices), through retailers, or through the media (including social media). Although there were some e-cigarette 'experts' in each of the vaping groups, more often than not, the participants in this study expressed uncertainty about the contents and safety of e-cigarette liquids, the safety of the devices, and about the long-term health impacts of vaping.

12.5 There were repeated calls for better, more trustworthy information, particularly regarding the health risks of using e-cigarettes.

What young adults think about e-cigarettes

12.6 The views of young adults about e-cigarettes were often closely linked to their experiences of using them. Smokers and vapers generally accepted the use of e-cigarettes as 'normal'. Non-smokers, on the other hand, saw it as a bit outside their experience - and in some cases, slightly odd. Although this was a minority view among this group of research participants, it is likely to be a majority perspective in the wider population of young adults, the majority of whom do not smoke tobacco.

12.7 Smokers and vapers largely saw e-cigarettes as aids to smoking cessation, and many approached the use of e-cigarettes with a history of previous unsuccessful cessation attempts. However, there was some scepticism voiced, particularly within the smoking groups, about the effectiveness of e-cigarettes in this respect. In contrast, those in the vaping groups (and those in the smoking groups who had made a commitment to vaping) often voiced more positive attitudes about the use of e-cigarettes for cessation. At the same time, however, they expressed mixed views about the efficacy of particular devices and certain e-liquids.

12.8 Those who had positive attitudes to e-cigarettes saw them as healthier and less anti-social than ordinary cigarettes. In contrast, those with negative attitudes considered them to be 'rubbish' - a description which referred not only to their perceived lack of effectiveness as smoking cessation aids, but also to the unsatisfactory sensory experience reported by some.

12.9 At the same time, young adults were also aware that the desire to quit smoking was not the only reason that their peers and younger people were using e-cigarettes. Sometimes e-cigarettes were seen as a more convenient, and less anti-social, way of getting nicotine and for some a way to cut down on smoking, rather than a way of stopping altogether. For others, vaping was a means of saving money. There was also a view that some people's use of e-cigarettes was just a 'hobby', for doing smoke tricks - and was just a 'passing phase'.

12.10 Non-smokers (including ones who had tried an e-cigarette) were generally uninterested in the devices. While this group thought some people believed e-cigarettes were 'cool', they themselves did not believe that and were not interested in using one in the future. There was also a general view that, while some people might initially be attracted to e-cigarettes because of the interesting flavours, the progression from e-cigarettes to smoking would be unlikely for most people.

Experiences of using e-cigarettes

12.11 Young adults' experiences of using e-cigarettes were complex and highly individual. However, the focus group design of this study did not allow scope to explore individual experiences in any depth.

12.12 Many of the young people in this study tried their first e-cigarette out of curiosity - often prompted by a pleasant fragrance or the desire to taste a particular flavour of e-liquid. Other motivating factors included cost, convenience, and the ability to vape secretly, without others being aware of one's use (compared to cigarette smoking). The social aspects of vaping attracted others: vaping appeared to be fun.

12.13 Participants described both positive and negative experiences of their first e-cigarette, and these experiences did not necessarily correlate with their desire or intention to take up regular vaping.

12.14 For example, among the few non-smokers in this study who had tried an e-cigarette, some enjoyed its flavour, but none had any interest in continuing to vape. Similarly, nearly all of the smokers in this study had tried an e-cigarette at some point, but for a range of reasons, some did not continue to vape despite, in some cases, a continued strong desire to quit smoking. Those who persevered with vaping were generally smokers who wanted to quit smoking, and who were willing (and could afford) to experiment with different devices and liquids until they found a combination that worked for them.

12.15 Many of the smokers and former smokers in this study had made previous unsuccessful attempts to quit smoking, and reported generally poor experiences of other cessation methods. Some stated that their use of e-cigarettes had helped them to quit, or significantly reduce their use of ordinary cigarettes, and that they saw improvements in their health as a result.

12.16 However, dual use of cigarettes and e-cigarettes was common in this group, and it was also clear that people moved in and out of vaping at different times. Again, these experiences were very specific to individuals but often related to the person's perceptions about: (i) the acceptability (or not) of smoking in certain locations and situations; (ii) the social context - who they were with and where they were; (iii) ease of access to e-cigarettes and cigarettes; and (iv) the relative satisfaction derived from a cigarette or e-cigarette in certain circumstances. Certainly, these experiences seem to suggest that patterns of using e-cigarettes are complex and variable.

12.17 The cost associated with e-cigarette use is an issue for young adults. On the one hand, the overall lower cost of vaping encouraged some to switch from tobacco cigarettes to e-cigarettes. On the other, the initial outlay could be a barrier to obtaining better quality devices which vapers argued were the key to successfully quitting smoking. These findings have particular implications for young adults - especially those who are unemployed - who are often on very low incomes.

Regulation of e-cigarettes

12.18 It was not part of the remit of this study to explore young adults' views on e-cigarette regulation. Nevertheless, the subject often arose during the discussions. In general, those who took part in this research were in favour of better regulation of e-cigarettes - particularly in relation to the sale of e-cigarettes to children, the safety of devices, and advertising.

12.19 There were more mixed views in relation to regulation of where people are permitted to vape, although the balance of opinion was in favour of some restrictions. Participants were not always persuaded that this was necessary on health grounds and some saw one of the advantages of vaping (over smoking cigarettes) as being the ability to vape indoors.

12.20 There was also a view that heavy taxation of the devices should be avoided because of the possible impact this might have on discouraging people to switch from tobacco cigarettes.

Public health implications of this research

12.21 This research study was undertaken in the context of ongoing debates about the health effects of using e-cigarettes and the potential role of e-cigarettes as a public health response to smoking.

12.22 The findings of this study indicate that young adult smokers in Scotland are experimenting with, and in some cases turning to, e-cigarettes in an attempt to quit smoking - often having failed in previous quit attempts using other smoking cessation methods.

12.23 The young adults in this study who were regular vapers generally reported that they had either quit or reduced their level of smoking, although the progression to less or no smoking was not always straightforward. This study suggests that experiences of using e-cigarettes are complex and very individual. It would also seem that particular devices suit some people but not others, and that young adults can be put off using e-cigarettes by an initial bad experience with a particular device or e-liquid.

12.24 At the same time, the research found that there is a great deal of confusion among this group about e-cigarettes, and little good quality information available from trusted sources to enable them to make an informed choice about how to use these devices to best effect. Concerns were voiced about the safety of the devices and liquids, and the frequency with which people appear to use their e-cigarettes ('it's never out of my hand'). Moreover, much of the perceived 'best' information available to young adults comes via word-of-mouth from friends or relatives, from the internet, or from retailers.

12.25 The research points to a clear role here for the public health community in providing good quality information while continuing to acknowledge that this is an area of emerging evidence. Further, increased understanding of the experiences and attitudes of young people - and those from other age groups - will be of interest to health promotion policy makers and practitioners who are exploring the role that e-cigarettes might play in encouraging and facilitating smoking cessation. The findings of this research suggest that it will be important to engage with young smokers, not only in terms of developing policy on e-cigarettes, but also in planning services to help people quit smoking.

Limitations of this research

12.26 As noted above, the focus group methodology used in this research meant it was not possible to explore people's individual histories of smoking and vaping. Nor was it the intention to carry out a detailed analysis of the relationships between individual participant characteristics (including smoking status) and their attitudes and experiences. This was an exploratory research study in an area where there has been very little investigation to date. The desire was to make a timely contribution to an emerging evidence base and a rapidly changing area of policy.

Conclusion

12.27 This research has provided valuable information on young adults' behaviours and attitudes relating to e-cigarette use - an area of interest to both policy makers and practitioners in the health field. The findings point to a need for the public health community to take a lead in providing information and advice to young adults in a context where there is little reliable information available.

12.28 This exploratory study has also offered valuable insights which will help to inform further research - either currently underway or planned - on e-cigarettes in the UK. Future research is needed to obtain a more detailed understanding of the circumstances of dual use of cigarettes and e-cigarettes, and the various, often non-linear, pathways that young adults take between smoking, vaping and the cessation of smoking. Further work on these issues will benefit from a longer term perspective, and will be able to build on the groundwork provided by this and other research currently being undertaken in this area.