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

6 Cessation experiences and the addictiveness of e-cigarettes

6.1 This chapter discusses young adults' previous experiences of smoking cessation - that is, experiences prior to their use of e-cigarettes. It also explores how they viewed e-cigarettes in terms of smoking cessation and what young adults believed about the addictiveness of e-cigarettes relative to ordinary tobacco cigarettes.

Young adults' experiences of smoking cessation

6.2 Smokers, former smokers and vapers were all asked if they had previously tried to quit smoking, and if so, to discuss their experiences.

6.3 Those who had made quit attempts in the past had tried most types of cessation aids, and participants were almost unanimous in the view that these aids had not worked for them, and furthermore, that they had significant unpleasant side effects. Nicotine patches caused allergic reactions, nausea, light-headedness and nightmares; the gum, spray and mouthwash all tasted 'disgusting'; and the 'puffer' caused headaches. Only very occasionally did a participant say that some type of smoking cessation aid had helped them to reduce their smoking.

6.4 Some participants said they had previously attempted to quit by 'going cold turkey' - with varying degrees of success ranging from half-a-day to two and a half years. Others talked about trying to distract themselves (by reading, playing video games or taking up a hobby), playing with elastic bands ('that worked a wee bit, yeah'), and spending money on other things ('so that you don't have money for fags').

6.5 There was a view among some that, 'if you are determined to quit, you can quit'. This view was echoed by some who had been unsuccessful in their previous attempts, who believed that their inability to quit was the result of a lack of 'willpower'. However, others had found it particularly difficult to maintain the motivation to quit smoking when they lived with parents who smoked, or when all their friends smoked.

E-cigarettes as smoking cessation aids

6.6 As discussed in Chapter 5, not everyone who used an e-cigarette did so because they wanted to stop smoking. However, this was certainly the most common reason given and participants believed that it was also the main motivation for other people they knew who used e-cigarettes. Thus, participants saw e-cigarettes primarily as smoking cessation aids.

6.7 In discussing their experiences of using e-cigarettes, smokers and vapers tried to explain what it was about an e-cigarette that helped them to quit smoking - or, by contrast, why vaping did not help them to quit smoking. These explanations often focused on the perceived pleasure (or perceived unpleasantness) of vaping, or on the similarities (or differences) between smoking and vaping. Both of these issues often came down to the devices or liquids that participants were using.

The quality of e-cigarettes and liquids

6.8 Young adults often attributed the less pleasant vaping experiences to poor quality, cheap devices and liquids. Switching to a better quality device and better quality liquids made a difference for some.

'I started on the pen and I kept going back to smoking, and then I thought, I'm just going to invest in a bigger one and it's worked.' ( FG6, Female, vaping group, under 21, in employment)

6.9 The exchange below also illustrates this point:

Male: 'When you wake up after drinking and smoking, you feel horrible.'

Female 1: 'Do you not feel, like, when you're drunk, though, you crave the fag?'

Female 2: 'No, see, I prefer using my vapour now, aye.'

Female 1: 'See, I was using a vape just completely, and then we went to a beer garden one day and it was sunny, and I was having a pint, and I was like "This just isn't cutting it", and that's when I went and bought a packet of fags and it all started again.'

Female 2: 'Don't get me wrong, I still get a craving when I'm drinking for a fag, but I prefer smoking that [e-cigarette] now when I'm drinking.'

Male: 'I think you need to have a half decent electric cigarette.'

Female 2: 'Aye.'

Female 1: 'Aye, that's probably…'

Male: 'See if you buy these ones that's all like string inside them and all that, forget that, that'll not work.'

Female 2: 'Aye it doesn't work, exactly.' ( FG11, vaping group, aged 19-25, in employment)

6.10 Vapers who regularly used mod boxes often said that they were better than other devices, because they allowed the user greater control over the level of nicotine and the amount of vapour produced by the device. Mod boxes were also reported by some to give the same 'kick at the back of the throat' that a cigarette does.

6.11 However, some participants said that they simply could not afford the large initial outlay required for a better quality device, and these individuals preferred to keep smoking cigarettes rather than continuing to use a cheaper device that they did not enjoy using. The issue of e-cigarette pricing is discussed in Chapter 9.

The similarities and differences between smoking and vaping

6.12 Those who were using e-cigarettes exclusively tended to focus on the more pleasant taste and smell of an e-cigarette, as compared with the 'disgusting' taste and smell of a cigarette. While some said they sought to replicate the taste of a cigarette (for example, by choosing a menthol flavour), others said that it had been more helpful to them to choose a flavour that was completely different to cigarettes (to break the association between vaping and smoking).

6.13 Some vapers talked about the importance for them of the hand-to-mouth action and the production of 'a cloud' from the exhalation of vapour which they felt helped to mimic the experience of smoking. The production of a vapour cloud appeared to have an important role for some, not only in staying off cigarettes, but in managing stress.

The addictiveness of e-cigarettes compared to cigarettes

6.14 Focus group participants were asked how addictive they thought e-cigarettes were in comparison with ordinary tobacco cigarettes. This question resulted in considerable debate within the groups.

6.15 Those who believed that e-cigarettes were not as addictive as tobacco cigarettes gave the following arguments to support their view:

• E-cigarettes are not as enjoyable as cigarettes
• E-cigarettes do not give the same 'draw' or 'hit' as a cigarette does
• Some e-cigarette liquids have little or no nicotine in them.

6.16 In contrast, those who believed that e-cigarettes were as addictive - or more addictive - than tobacco cigarettes pointed out that e-cigarettes usually contained nicotine. This group commented that people who use e-cigarettes seem to use them constantly, and do not know when to stop using them. Therefore, it appears that vapers are getting far more nicotine from an e-cigarette than they did from a tobacco cigarette simply because they are using them all the time. This line of argument led this group to conclude that e-cigarettes are more addictive than cigarettes.

Addiction vs habit

6.17 However, young adults were clear that the addiction to nicotine was only one aspect of a dependence on cigarettes. While some recounted their own experience of reducing their nicotine levels over time until they were using e-liquids with no nicotine content, or of finally finding a level of nicotine that satisfied their craving for cigarettes, others focused on the habit of smoking and the rituals they had developed in their lives around smoking cigarettes.

6.18 Some participants thought their addiction to nicotine was not the issue; rather they found that an e-cigarette was helpful in allowing them to replicate the hand-to-mouth motion that was a big part of smoking (and which patches and sprays and nicotine gums did not do).

6.19 However, others talked about the challenges of establishing new and different habits when using e-cigarettes, particularly given the very common experience that people had of 'constantly using it' and 'never having it out of their hand'. Some believed that they should try to vape at the same times and in the same places as they smoked. Others disagreed: it was better for them to break the association with smoking entirely, including by avoiding situations where they would have previously smoked.

6.20 As noted above, there was also a view that switching to e-cigarettes was simply 'swapping one addiction for another'. Some participants were unconcerned about this and happy to continue to use e-cigarettes indefinitely; others disliked this idea and so aimed to reduce their dependence on e-cigarettes as quickly as possible.

6.21 Ultimately, participants believed that issues of addiction and habit were very specific to individuals.

There are some circumstances in which people prefer or need a cigarette rather than an e-cigarette

6.22 At the same time, young adults who used both e-cigarettes and ordinary cigarettes explained that there are certain circumstances in which only a cigarette will do. Although there was some debate within the groups about the extent to which an e-cigarette was as 'effective' or 'satisfying' in those circumstances, nevertheless, there appeared to be a shared understanding among smokers and vapers about why some people might resort to a traditional cigarette in these circumstances. These included: (i) when drinking, (ii) during times of stress, and (iii) first thing in the morning.

When drinking

6.23 Vapers and smokers noted that people who smoke often smoke more when they are drinking, and people who vape throughout the week will often switch to cigarettes when they are out drinking at the weekend.

'I was on the vaporiser because I went from smoking about 20 a day when I was travelling, and then came off and then went onto the vaporiser. Then I eventually came off cigarettes through the vaporiser, but I can't stop smoking when I'm drinking, or socially in a pub or around people that are smoking.' ( FG8, Male, smoking group, aged 19-25, in employment)

'I had stopped [smoking] for a full year without anything, but I still smoke and use the e-cig just now, because I went back to it. By drinking I ended up starting smoking again.' ( FG11, Male, vaping group, aged 19-25, in employment)

6.24 Non-smokers also commented on the association between smoking and drinking, and a few non-smokers said that their first use of an e-cigarette was when they were drunk.

6.25 For some young adults, the desire to smoke, rather than vape, when drinking was related to taste. One young man said, 'I think vaping and drinking would be a bit weird - a Corona and bubble gum!' Another referred to the smell of cigarettes which triggered a strong craving: 'See, if I'm sitting in the pub and my pal is going out for a fag, oh, you smell it, and you're, like, "I need a fag now. I need one now.'''

6.26 The social aspect of 'going out for a fag' and being part of a social group of smokers was also contrasted with the alternative of being left inside alone. As one participant said: 'It doesn't help when the majority of your friends are smokers, because they're not going to be like, 'Oh well, you're smoking an e-cig, I'll stay inside with you.''

During times of stress

6.27 Just as the situation of drinking in a pub with friends triggered a craving for tobacco cigarettes, so also did stress. Some smokers and vapers recounted their experiences of regular vaping which came to an end when a particularly stressful event occurred in their lives. Other dual users explained that their tobacco smoking was restricted to stressful situations, and there was a view amongst some vaper-smokers, particularly those who were unemployed, that they would find it difficult to stop smoking simply because of the stress of life.

'Yeah, I just really smoke when I'm stressed out and that. I'll have a packet of fags there and if I need to smoke I'll have a fag. If not, I'll just vape.' ( FG10, Male, vaping group, aged 16-19, unemployed)

'If you're an ex-smoker, for someone that's trying to stop smoking, the minute there's a stressful situation, the first thing they do is go and get a fag.' ( FG9, Female, smoking group, aged 16-19, unemployed)

7.28 Those who highlighted this issue believed that 'smoking helps you calm down' in a way that vaping does not. One young woman commented that she had initially learned this from her mother:

'Like, even when you were younger, you'd ask your mum, "Why are you having a fag for?" And she was like, "Oh, I'm stressed." So you're thinking that will calm you down. So, that mind-set, that fags will calm you down, whereas a vape, you don't know… it doesn't seem to calm you down.' ( FG9, Female, smoking group, unemployed)

6.29 There was also a view that the process of rolling a cigarette is 'quite soothing', and that 'filling a tank of vape' cannot produce the same sense of satisfaction.

First thing in the morning

6.30 The 'need' for a cigarette first thing in the morning was discussed less often, although for some it accounted for their only cigarette of the day:

'I always have a fag in the morning, I have to admit, so I usually start [vaping] maybe about lunchtime.' ( FG7, Female, vaping group, aged 19-25, unemployed)

'Nothing beats that morning cigarette. You can vape all day and just like "oh it's ok", but that first one in the morning is just magnificent, honestly!' ( FG6, Male, vaping group, aged 16-21, in employment)

6.31 Smokers and vapers clearly had a shared understanding of why some people would choose a tobacco cigarette in such circumstances, although it is important to reiterate that not everyone agreed that e-cigarettes were unsatisfying at these times.

6.32 Indeed, in relation to drinking, some vapers said that they now preferred to vape when drinking because they disliked feeling sick the next morning after a night of combined smoking and drinking, or because they preferred to sit inside and drink rather than stand outside in the cold and rain. One young man said he had stopped smoking entirely, and had largely stopped vaping - but he continued to vape only when he was drinking. Another said that going outside to vape with his mod box often resulted in good conversations with smokers.

6.33 In relation to coping with stress, one young woman said that when she feels stressed, she just turns up the watts on her mod box 'to make bigger clouds', and this has a calming effect on her. Others said they simply vaped continuously when they were stressed.

6.34 Others vapers said that they had stopped having a cigarette first thing in the morning because they felt it tasted horrible.