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

Abstract

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.

Keywords:

• Harm reduction
• tobacco
• substance use
• public health

Introduction

By any measure electronic cigarettes have had a remarkable development. Barely seen ten years ago these devices, which enable flavoured, and often nicotine containing e-liquids, to be inhaled in vaporised form, are now being openly used in cities across the world. The Centres for Diseases Control and Prevention has estimated that there may be around 9 million e-cigarette users within the United States (Schboeborn & Gindi, 2015), whilst within the U.K. the anti-smoking group "Action on Smoking and Health" has estimated that there may be around 2.8 million e-cigarette users: 98% of whom are either current smokers or ex-smokers with only around 2% being people that have never smoked (ASH, 2016). In the light of those figures it is perhaps hardly surprising that the e-cigarette industry has been projected to be worth around $50B by 2025 (BIS Research, 2016)

According to a recent report from Public Health England, e-cigarettes are thought to be around 95% less harmful than smoking combusted tobacco (PHE, 2015b). As well as being less harmful, there is also evidence that e-cigarettes are playing an important role in helping smokers’ to quit (Bullen et al., 2013). Researchers working on the UK based “Smoking Toolkit” study have reported that individuals trying to quit smoking using e-cigarettes are more likely to remain abstinent than those seeking to quit using either “over the counter” nicotine replacement or a cold turkey approach (Brown, Beard, Kotz, Michie, & West, 2014). In its recent report “Nicotine Without Smoke: Tobacco Harm Reduction” the Royal College of Physicians has noted that “….e-cigarette use is likely to lead to quit attempts that would not otherwise have happened, and in a proportion of these to successful cessation (RCP, 2016:143). Similarly, Public Health England has commented” there is also evidence that (electronic cigarettes) can encourage quitting or cigarette consumption reduction even amongst those not intending to quit or rejecting other support (Public Health England, 2015a: 10).

However, as the popularity of e-cigarettes has increased so too have concerns about some aspects of their use. Attention has been drawn to the lack of high-quality data on the impact of e-cigarettes used over the long term (Callahan-Lyon, 2014); to the possibility that e-cigarettes might result in increased levels of nicotine dependence (Fillon, 2015); to the fact that some smokers are dual using both combustible and vapour based nicotine products thereby potentially increasing their toxicant exposure (Adkison et al., 2013; Grana, Benowitz, & Glanz, 2014); to the possibility that former smokers are being reintroduced to nicotine as a result of taking up e-cigarette use having previously quit smoking (Durkin, Bayly, & Wakefield, 2016); to the variable manufacturing quality of some e-cigarettes resulting in reports of devices exploding (Yang, Rudy, Cheng, & Durmowicz, 2014); and to the accuracy of the labelling of some e-liquids particularly with regard to misleading information on nicotine content (Goniewicz, Hajek, & McRobbie, 2013; Goniewicz, Kuma, Gawron, Knysak, & Kosmider, 2013).

Attention has repeatedly been drawn to the fear that e- cigarettes might act as a gateway to smoking or a means of renormalising smoking (Alwasi, Nour, & Prabhu, 2015; Barrington-Trimis, Behane, & Unger, 2016; Leventhal et al., 2015; McKee, Chapman, Daube, & Glantz, 2014). The fear that e-cigarettes might act as a smoking gateway have been driven in part by research in the U.S. which has shown that young people reporting past e-cigarette use are more likely (on follow-up) to report having smoked combustible cigarettes. Wills and colleagues, for example, have reported the results of their longitudinal survey of 2338 high school pupils in Hawaii, which found that the probability of pupils’ smoking was significantly greater in the case of those pupils who had previously used an e-cigarette than amongst those who had not previously used e-cigarettes (Wills et al., 2016). However, as Bell and Keane have pointed out the very notion of a gateway effect is highly complex constituting “a hybrid of popular, academic, and media accounts” rather than a coherent theory (Bell & Keane, 2014). The claim that e-cigarettes might act as a gateway to smoking would require much more than the finding that those young people using e-cigarettes are more likely to go on to smoke than those that do not. For example an alternative explanation of that finding may be that both vaping and smoking have similar antecedents such that it is not vaping that is leading to smoking but another variable (for example, a willingness to experiment with different forms of drug use, or an attitude of rebelliousness) that is driving both vaping and smoking.

While some researchers have sought to identify a possible mechanism through which a gateway effect might be occurring by pointing to the possible role of nicotine (Kandel & Kandel, 2015), the extent to which nicotine is even being consumed by young people using e-cigarettes is by no means universally accepted. Miech at colleagues (Miech, Patrick, O’malley, & Johnston, 2016) have shown that the consumption of non-nicotine containing flavoured e-liquids was actually more common than the use of nicotine containing e-liquids. Similarly, Measham and colleagues (Measham, Obrien, & Turnbull, 2016) have shown that many of the young people in their qualitative research were more interested in the theatricality of being able to create large plumes of exhaled vapour than in meeting their need to consume nicotine (Measham et al., 2016).

Whilst the claim that vaping might serve to re-normalise smoking has been made by a number of researchers (Barrington-Trimis et al., 2016), it is not at all clear what is being meant by a process of "smoking renormalisation", how such a concept is being measured, or indeed how one would attribute an increase in smoking renormalisation to the use of e-cigarettes in particular. It has been suggested that one mechanism through which a renormalisation effect might be occurring is the visual similarity between vaping and smoking (Wills et al., 2016). However, whilst it is certainly the case that early generations of e-cigarettes were visually quite similar to combustible cigarettes, the subsequent and more recent development of the technology has resulted in vaping becoming visually quite distinct to smoking. Recent research has shown that those witnessing others’ e-cigarette use experience no difficulty in distinguishing between vaping and smoking such that it is hard to see why one activity (vaping) should result to another activity (smoking) becoming renormalised (McKeganey, Barnard, & Russell, 2016). Indeed, in the study undertaken by McKeganey and colleagues there was some evidence that amongst the non-smokers interviewed, attitudes towards smoking had become even more negative as a result of what was seen to be the availability now of a less harmful means of consuming nicotine (McKeganey et al., 2016).

Although these various studies are undoubtedly important in assessing the public health impact of e-cigarettes, there is also need for a more sociologically informed research on e-cigarette users experience. In this paper we report the results of qualitative research in which we have sought the views of e-cigarette users about how they came to start vaping, what they like most and like least about vaping, their judgements about the relative harm of smoking and vaping, their views as to how similar or dissimilar the activities of vaping and smoking are, whether in their view their likelihood of smoking had increased or decreased as a result of their vaping, and what they think about proposals to ban e-cigarette use within enclosed public spaces.

The research

Over the last year we have undertaken semi-structured interviews with 50 e-cigarette users aged between 16 and 26 (average age 20.9), 32 males and 18 females. Twenty-eight of our interviewees were current smokers, 19 were former smokers and 3 were never smokers. None of those who had smoked had initiated smoking after starting to vape. Interviewees were recruited from a range of educational settings (universities/colleges), leisure, and work settings across the North of England and Scotland drawing on social networks of young people within the various settings. Interviewees were provided with a payment of £15.00 to cover their time being interviewed and any associated costs in attending for interview. Interviews were undertaken by a team of six peer interviewers (three females and three males) aged between 17 and 30 who received training from one of the authors (MB) who also reviewed with each individual interviewer their first interviews to ensure that interviewers were completing the topic guide.

The inclusion criteria for our study were that the individual needed to be aged between 16 and 30 with either current or past experience of having used e-cigarettes. All of the interviews were audio recorded, transcribed, and subjected to detailed content analysis around the key themes of initiating and maintaining e-cigarette use, perceptions of e-cigarette use/users/smoking/smokers, perceptions of whether the individual’s view of smoking had changed following e-cigarette use, and whether in their view their likelihood of smoking had increased as a result of their vaping.

Initiating and maintaining E-cigarette use

In describing the circumstances in which they first used an e-cigarette the majority of our interviewees outlined situations in which they were with friends who had been using an e-cigarette, where they were curious about the experience of vaping, and where they had either asked to try the equipment or been offered a try of the equipment by their friends:

Someone I knew had one and I was curious to be honest because I’d seen other people with them and then I just thought I’d give it a shot. it was just a one off thing purely out of curiosity to see what it was like. (21 year old male, occasional vaper)

Just to see what everyone was raving about that were using it as they were saying it was just so much better than normal cigarettes that I thought I would give it a shot. I think the first couple of times I tried it that person offered me it but then a couple of other times after that if I’d been on like a night out or something or if they’d got a new flavour I just asked if I could try it. (21 year old male past occasional vaper)

I was in a friend’s house from my old school and it was on the table and he was doing it and I was like “what is that?” and they were smoking outside and we were the only ones who didn’t smoke so I was like “what is that?” and he said “it’s a vape, it’s basically like smoking but you don’t get the nicotine because there was no nicotine in it but it gives you the sensation of smoking” and he was like “do you want to try it?” and I tried it and it was really weird because it made me cough because I thought it would be more like a cigarette and loads of smoke went into my mouth and it made me cough. (17 year old female occasional vaper)

Interviewees often cited the perception that e-cigarettes were less harmful than combustible tobacco as a factor in explaining their initial interest in “trying out” the vaping experience:

The fact that they supposedly are not as harmful as cigarettes and just because I was curious what it would be like and how it would be similar to smoking actual normal tobacco, just the curiosity basically. (19 year old female occasional vaper)

The most frequently mentioned reasons for continuing to vape, beyond initial experimentation, had to do with the range of flavours that could be used, the element of fun associated with the use of e-cigarettes, the lack of an offensive smell that accompanied their use, the greater range of settings within which they could be used, and the reduced stigma that was associated with their use compared to smoking:

Because when you’re vaping it smells nice. I mean sometimes I’ll like the smell of a cigarette but the smell of a vape everyone likes if you know what I mean. When I was about eighteen I was using them but they weren’t about stopping smoking or anything because I was smoking at the same time. I just liked the flavour and liked playing with the smoke and liked being able to smoke indoors as well. That was a big thing for me because until I moved to University I was never able to smoke indoor so I quite liked the novelty of lying smoking my e-cig in bed. (22 year old male occasional vaper/smoker).

Well the flavour tasted really good and it was like fun, it was kind of a bit of fun really and it tasted good. It did give you a bit of a head rush really and the fact that it’s slightly healthier gives you a lot of motivation to do it instead of smoking. (22 year old female occasional vaper).

Like I’ve never had a desire to do it, it’s just if it’s there and I can do cool things with it, just something to play with, it’s not like I need to try it, like I feel I need to vape. I just like blowing circles with the smoke and trying like tricks and stuff like that it’s kind of interesting seeing how smoke works. (17 year old female occasional vaper).

Well the fact that in some places you can vape in-doors so I think people don’t feel not victimised exactly but like if you smoke tobacco you’ve got to go outside to smoke and I feel like people are not discriminated exactly. I can’t think of the word I’m trying to say but they might not feel part of the group because they’ve got to keep going outside to smoke but it’s a more social thing to be able to use them indoors. (21 year old male current vaper)

What was striking in these accounts of the reasons why individuals persisted in using e-cigarettes, beyond their initial experimentation, was the fact that none of the interviewees explained their continued use in terms of a felt need to relieve the effects of nicotine withdrawal. Similarly, none of our interviewees described their use of e-cigarettes in terms of a planned attempt to stop smoking. The predominant impression conveyed by our interviewees was less one of their e-cigarette use having become a regular, entrenched, part of their everyday lives so much as it being a rather fluid behaviour in which their interest in vaping, and their involvement in vaping, varied depending upon the particularities of their circumstance:

I’ve never owned one myself but I would use one of my friends just to try it out to have a little play I suppose. (21 year old male current vaper).

Our finding that many of our interviewees were using e-cigarette on only an intermittent basis is congruent with recent research from the U.S. in which Miech and colleagues surveyed 14,983 school pupils in the US. Whilst more than a quarter of pupils reported having used e-cigarettes at some point in the past (26.9%) only 4.1% of pupils had vaped on more than six occasions in the last 30 days (Miech et al., 2016).

Perceptions of harm

The predominant view amongst our interviewees was that e-cigarettes were seen as being substantially less harmful than combustible tobacco:

E-cigs are less harmful than smoking because it’s not got the same toxins and fumes and tar in it. I’m not really aware of how harmful it is, but it’s got to be better for you than smoking. (21 year old female occasional vaper).

Well obviously people know the damage that can be done by smoking tobacco and I think smoking tobacco is a lot worse to the user themselves and everyone around them because second hand smoke obviously can affect anyone. I’m not sure about the second hand smoke with vaping bit I’m guessing that it’s really negligible the damage that can be done so I think definitely cigarettes and tobacco are still quite a bit worse than vape. (22 year old male occasional vaper).

Whilst there was a predominant view that vaping was substantially less harmful than smoking this did not mean that our interviewees viewed e-cigarettes as harmless. Rather, e-cigarettes were seen as having a number of potential harms. Some of our interviewees drew attention to reports they had seen in the news media suggesting that e-cigarettes were as harmful as normal cigarettes. Others had sourced information on the internet in an attempt to form an understanding themselves of the current science around the relative harm of e-cigarettes and normal cigarettes:

I’ve read a few studies online like initially when they were brought out everyone was like they’re not harmful but then there were studies that said vaping was just as harmful because there’s chemicals in it and I can’t remember exactly but the chemicals in it are just equal to smoking almost, you know, there’s just so many unknown chemicals that you’re breathing in that can damage you so I think they can be bad but there’s this belief that it isn’t bad and a lot of people think that it’s good for you and that’s why some people can start vaping because they’re like oh yeah it’s just like smoking and it’s not damaging you but in reality anything with chemicals in it is bad for you. (22 year old female occasional vaper).

Some interviewees commented that although they believed e-cigarettes were less immediately harmful than smoked cigarettes, nevertheless in the longer term, hitherto unknown harms might emerge in much the same way as had occurred in relation to smoking:

I think it took over 40 years for them to find out smoking was really bad for you so I don’t know whether they will come out with something in the long term that will say it’s bad for you but I don’t think they’ve went into it. (21 year old male past vaper).

I’ve always thought it probably will be quite harmful and in the future it’ll come out that it’s quite harmful but I don’t know at the moment as I’ve not really heard anything about them being harmful. I don’t know if I fully trust them because you’re still taking things into your lungs and that’s not really healthy to do that with anything. (22 year old male past vaper)

Alongside the perception that e-cigarettes might be associated with some unknown longer-term harm, there was also a view expressed by some of our interviewees that the potentially addictive nature of e-cigarette use was something that concerned them:

I’m not a hundred per-cent sure exactly what it does for you other than it doesn’t have the tar, it doesn’t create the tar but I still think it isn’t good to be addicted to something and people are constantly using them, like there’s people addicted to alcohol and there’s others who are addicted to, I don’t know, drinking too much coke (coca cola) or something and although it might not be as harmful it can impact on other things like you might have to depend on it and I think that’s bad because you shouldn’t have to depend on something. (22 year old female occasional vaper)

In general, our interviewees perceived vaping and smoking as being associated with very different levels of harm though there was a recognition that in the future other harms might emerge that were associated with the more long-term use of e-cigarettes and the evolving science of inhaling e-liquids.

Perceptions of the similarity of vaping and smoking and the possible impact of vaping on smoking

Amongst our interviewees there was a clear split between those who viewed vaping and smoking as being similar and those who viewed these two activities as being substantially different. Amongst those who viewed vaping and smoking as being somewhat similar attention was drawn to the fact that both activities involved inhalation

I think it’s probably the same because you have to inhale them and like breathe them in from something but I think probably quite different because I think a cigarette kind of burns and vapes are just there, they’ll always be there, you can’t really run out of it, you throw your cigarette end away but you wouldn’t do that with a vaper. (16 year old male occasional vaper)

Alongside the shared route of inhalation some interviewees also commented that the two activities could be visually similar:

It looks like smoking, you do appear to be smoking but then as I mentioned earlier you don’t get this horrible smoke or the same sort of atmosphere that’s created by smoking I don’t think. (21 year old male occasional vaper/smoker)

Attention was also drawn to the similarity between vaping and smoking in terms of the common presence of nicotine in the substances consumed:

Because once you start smoking the vaper you’re getting the nicotine anyway so it starts to become a physical addiction so regardless of whether you’re smoking the vaper or you’re smoking a cigarette you’re still going to need the nicotine if you become addicted. (23 year old female occasional vaper)

Those who viewed smoking and vaping as somewhat similar drew attention to what they regarded as the common element of dependence associated with vaping and smoking:

It’s exactly the same addiction and habit and your funding the same thing…it’s all the same basically so in terms of quitting smoking I think e -cigarettes are just the easy route, it is literally just swopping your addiction from smoking tobacco smoking nicotine filled liquid you’ve never kicked the habit it’s still there and if you broke your e-cig you’d probably end up going into the shop and buying tobacco. (16 year old occasional vaper/smoker).

Interviewees who said that in their view vaping and smoking had very little in common identified a range of differences. For some there was a clear visible difference in the smoke and vapour produced from an e-cigarette compared to a normal cigarette:

They’re clearly different to me. The smoke that comes off vape is big plumes that last a lot longer than cigarette smoke and also you can smell them a lot of the time before you see them with all the different flavours they have. (22 year old male occasional vaper)

If I turn around and see smoke coming out of someone’s mouth, I would look back and then I think I would see that actually they were vaping and not smoking a normal cigarette. It looks quite common but when you actually see what they’re holding to their mouth it’s quite different. (16 year old occasional vaper)

Some of our interviewees cited the fact that e-cigarettes and normal cigarettes produced a very different taste and smell as being clear evidence of just how dissimilar the products were:

In comparison to cigarettes I’d probably say it smells better in the long run, it doesn’t get in your clothes or whatever, seemingly healthier because we don’t really know yet, eh I don’t really know if it’s cheaper because I’ve never owned one myself so I can’t say that and probably it’s better for you I reckon and a bit more fun. (21 year old male occasional vaper/smoker).

Interviewees were asked whether in their view vaping had resulted in smoking becoming more socially acceptable and whether they felt their likelihood of starting to smoke or resuming smoking had increased as a result of the growing popularity of e-cigarettes. The consensus amongst our interviewees was that no such effect had occurred and that vaping had, if anything, made smoking less not more acceptable. Such comments as the following were typical of our interviewees:

I think vaping is having an effect on smoking cigarettes in that it’s taking it away from it. People are moving off the cigarettes and moving on to vaping because it’s the next, as I said, cool thing. I don’t think it’s having an effect of making people smoke because they’re vaping, I think it’s taking away from smoking cigarettes. (22 year old female occasional vaper)

I think smoking is less acceptable if anything because there’s an alternative now to smoking cigarettes so in that way I think its maybe the opposite of having made smoking more acceptable. (26 year old female occasional vaper)

Because smoking is less healthier so vaping becomes more common if anything. I think smoking would be less accepted because it would be like well there’s an alternative that’s better for you, it’s less offensive to people around you so why are you smoking when you could be vaping. I think it would make smoking less accepted if vaping got more popular. (22 year old male ex-smoker occasional vaper)

There were a small number of individuals who expressed the contrary view that the increasing popularity of vaping might in some circumstances result in smoking becoming more common or more popular:

I think when they first came out it was almost like they made smoking redundant a bit when people first found them because people thought they were fun and a bit healthier. I think that made smoking seem pointless, but when all this stuff came out about them being bad and being made fun of I think that almost glorified cigarettes a bit because people who smoked would think so why are you having a stupid vape.(21 male year old occasional vaper)

To further explore whether vaping had increased the likelihood of people smoking, our non smoking interviewees were asked whether in their view they were more or less likely to smoke now that they had used e-cigarettes. The overwhelming majority of those questioned said that in their view their likelihood of smoking had remain unchanged even in the face of their e-cigarette use:

The likelihood of me smoking) is probably the same. I mean I was quite curious of e-cigs at first but just as I was with smoking to start with. I think it’s just sort of a phase that will die out. For me anyway it (smoking) just doesn’t really interest me. 26 year old past vaper)

Chances of me smoking are zero- it’s just not something that I’ve had any interest in. (24 year old male occasional vaper)

I’d say it’s (likelihood of smoking) stayed the same I’ve been quite opposed to smoking in any form for a long time so I don’t think it’s changed particularly. (24 year old female occasional vaper)

A small number of interviewees commented that if they were to think about starting to smoke now they would be more likely to use an e-cigarette than a normal cigarette:

If I was to smoke now I would go for an e-cigarette because I am scared of getting hooked. So I don’t want to get hooked so I would go for the e-cigarette. (21 year old female non smoker tried vaping in the past)

Finally interviewees were asked whether in their view vaping should be allowed within enclosed public spaces or banned from such spaces (as occurs in many countries with regard to smoking).

Vaping in public

Interviewees were divided as to whether in their view vaping in enclosed public spaces should be banned. Amongst those who felt that such a ban would be unfair the basis for their view largely had to do with the belief that passive vaping posed little or no health harm to non-vapers and on that basis banning vaping in public spaces would be unfair and unreasonable:

The effects of vaping haven’t been proven in terms of its damages so I don’t see why it should be banned for people that are trying to get off smoking- if they are wanting a fag they can just have a little toot of the vape. So I think its fine in public places. (16 year old male non smoker occasional vaper).

Maybe not because it doesn’t give off harmful fumes so its not harmful and its not that horrible smoke that you do get so it doesn’t really effect anyone. Like I wouldn’t be put of by being in an enclosed space if they were there, but maybe if they were smoking I would feel that that’s wrong and that I really don’t like that. (21 year old non-smoker occasional vaper)

In contrast to those who felt that it would be unfair to impose a ban on the use of e-cigarettes in public The reasons offered in support of such a ban were more varied. For some of those interviewed the case in support of a ban had to do with the issue of minimising the nuisance to other people that could be caused by vaping:

Yeah I think so even though there isn’t an issue with passive smoking with an e-cig it’s still the same. I know the health problems aren’t there to such an extent but it’s still quite distracting and even although it’s a personal choice, in public areas it affects other people as well so I’d say restrict it. (21 year old female non smoker)

Yeah I think it should be because even if you are in a restaurant regardless of whether the steam or vape is like harmless or not no one really knows yet but if you are sitting there having dinner and you keep getting big wafts of steam coming over it just kind of ruins your environment. (21 year old male non-smoker occasional vaper)

Aside from the annoyance that some interviews clearly felt around the issue of people vaping in public settings it was clear that some people felt that a potentially positive outcome of such a ban would be the help it offered vapers in reducing their vaping:

It doesn’t bother me that much but I think sometimes because they can smoke it in public places it means that they smoke it more whereas they should probably have to go outside because it defeats the purpose of changing to an e-cigarette. (19 year old female non-smoker occasional vaper)

Finally, some interviewees explained their support for such a ban as a means of reducing young people’s exposure to vaping:

It’s a bit strange. I don’t know the health risks if there are any I would say probably not. However, because it is allowed inside a lot more people are exposed to it. So like younger kids might see someone who is like in a restaurant doing it and they might be like oh I want to try that which obviously, again I don’t know the health risks but yeah I think its something to be looked at that it is more widely exposed to younger people. (21 year old male non-smoker)

It is interesting that the issue of whether e-cigarette use should be allowed within public settings clearly divided even this relatively small sample suggesting the diversity of views around the issue of how to respond to the still relatively new behaviour of people using e-cigarettes in public view.

Discussion and conclusion

On the basis of the qualitative interviews we have undertaken with 50 e-cigarette users whose ages range from 16 to 26 there were substantial perceived differences between e-cigarettes and normal cigarettes. Our interviewees saw the two activities of vaping and smoking as being associated with very different levels of harm. None of our interviewees felt that their e-cigarette use had increased their likelihood of smoking even if a small number conceded that this might be the case for other people. In terms of how individual interviewees had begun vaping this had largely occurred in the midst of their social contacts with friends in which they had either asked or been offered a try of friends’ equipment and within which curiosity seemed to be a key driver of such experimentation. With regard to the decision to continue vaping, attention was drawn to such factors as the lower levels of harm associated with vaping compared to smoking, the availability of different flavours, the lack of an offensive smell associated with vaping (again in contrast to smoking), the fun that was seen to be associated with creating large vapour plumes, the greater range of situations within which one could use e-cigarettes compared to combustible cigarettes, and the lower level of stigma attached to vaping compared to smoking. Whilst it may be thought surprising that our interviewees seemed broadly evenly split on the issue of whether vaping in public spaces should be banned it is perhaps important to note that predominantly our interviewees were using e-cigarettes on only an occasional basis. Ours was not a sample of confirmed vapour advocates but rather a sample of relatively young people whose e-cigarette use was more an occasional part of their activities rather than an entrenched part of their lifestyle.

As the use of e-cigarettes, particularly amongst young people, has increased so too has the level of concern around that use. Most recently the Surgeon General within the United States has issued a report which, amongst other things, has recommended the prohibition of vaping in enclosed spaces, restrictions on the sale of e-cigarettes to young people, restrictions on young peoples’ access to e-cigarettes, the imposition of restrictions on where vaping can occur, the adoption of taxation policies that ensure e-cigarettes remain relatively expensive, and restrictions on the marketing of e-cigarettes (U.S. Department of Health & Human Services, 2016). The predominant policy response, within the Surgeon General’s report, is one of surrounding vaping with increasingly restrictive regulations.

There is a danger here that public policy is being increasingly driven by concerns arising from the apparent increase in the prevalence of their use by young people rather than by the evidenced benefit of e-cigarettes in facilitating a reduction in smoking prevalence. In forming an appropriate public policy response to e-cigarettes it is clearly important that the potential contribution of e-cigarettes with regard to reducing smoking prevalence is enhanced at the same time that the potential harms of e-cigarette use are reduced. Achieving those two goals will require us to maximise the appeal and access of e-cigarettes to current smokers whilst reducing their appeal to non-smokers. To achieve that balance it will be necessary to build up a detailed picture of how these devices are being used, by whom, for what reason, and with what effects. Our own interviews with a small sample of relatively young vapers shows that it is possible for at least some of the use of e-cigarettes to be occasional and intermittent rather than protracted and regular. This is not to suggest that e-cigarettes do not have the capacity to stimulate a pattern of dependent use but it is to recognise that there is likely to be more than a single style of use particularly where this involves young people.

If we are to balance both the benefits and the potential harms of these devices it will be necessary not only to continue to undertake large scale surveys following samples of e-cigarette users over time (to determine amongst other things whether a smoking gateway is occurring and the long term impact of e-cigarette use) but also to build up a detailed picture of the variety in the ways in which these devices are being used- in effect an ethnography of vaping in which we are better able to understand how and why people choose to vape (or not) the situations in which they vape, how they determine the frequency of their vaping, the reactions of others to the fact of their vaping, the impact of legislation and regulation. Crucially, because the technology of electronic nicotine delivery systems is changing so rapidly it will be important to ensure that the research effort directed in this area is able to keep pace with those developments and the speed of their impact on users.

Declaration of interest

The research reported in this paper was funded by Fontem Ventures which is an e-cigarette manufacturer and non-tobacco based subsidiary of Imperial Brands Group.

Acknowledgements

Fontem Ventures had no role to play in the design of this study, in the collection and analysis of the data, in the preparation of this manuscript, nor in the decision to submit the manuscript for publication. The research upon which this paper is based received a favourable assessment from the ethics committee at Strathclyde University, Glasgow Scotland.