Characteristics, use patterns and perceptions of electronic cigarette users who were never traditional cigarette smokers

Abstract

Since their introduction in the United States in 2007, electronic cigarettes (e-cigs) have risen in popularity. A nationally representative sample of adults showed that between 2010 and 2013, ever use of e-cigs increased from 1.8% to 13% (McMillen, Gottlieb, Shaefer, Winickoff, & Klein, 2015). While use is significantly higher in those who are current or former smokers (Delnevo et al., 2015), there is concern that e-cigs may appeal to never cigarette smokers and cause them to become nicotine dependent (Cobb, Hendricks, & Eissenberg, 2015). Based on 2014 data from the U.S. National Health Interview Survey, 2.8% of never cigarette smoking adults had tried e-cigs, and 0.4% were currently using them some days or every day (Delnevo et al., 2015). Although many cigarette smokers report using e-cigs as a smoking cessation or reduction tool (Foulds, Veldheer, & Berg, 2011), it is unclear why never cigarette smokers are using e-cigs. Never cigarette smoking e-cig users are important to understand as they have the potential to develop nicotine addiction through a new mode of delivery that has similarities to a cigarette (McMillen et al., 2015). While it is certainly possible that never tobacco users are initiating nicotine use with e-cigs, the majority of the literature focuses primarily on youth populations. Some studies have found evidence of e-cig uptake among never cigarette smoking adolescents, although rates of e-cig use are still higher in adolescent cigarette smokers (Bunnell et al., 2015; Camenga et al., 2014). They have also found there may be differences in risk factors for tobacco product use among adolescents using e-cigs vs. combustible cigarettes and those at intermediate levels of risk may engage in e-cig use when they would not have otherwise been susceptible to tobacco product use (Wills, Knight, Williams, Pagano, & Sargent, 2015). While these studies assume that adolescents are initiating nicotine use with e-cigs, a recent study has shown that a significant proportion of adolescent e-cig users are using e-cigs that do not contain nicotine (Miech, Patrick, O'Malley, & Johnston, 2016). Adults may differ from adolescents in their reasons for use and use patterns but there have been few studies that have examined e-cig use among adult never cigarette smokers. A comprehensive survey study conducted by Farsalinos et al. included an analysis of the use patterns of e-cig users who were never cigarette smokers, but it did not account for traditional tobacco product use aside from cigarettes (e.g. cigars, hookah, pipes, and chew) (Farsalinos, Romagna, Tsiapras, Kyrzopoulos, & Voudris, 2014). If the never cigarette smokers are current or past traditional tobacco product users taking up e-cigs as an alternative to traditional tobacco, it is not the case that they have initiated their nicotine addiction with e-cigs. For instance, Berg conducted a quantitative survey of young adult e-cig users including a full tobacco use history and found that more than 75% of never cigarette smokers had used at least one other tobacco product in their lifetime. Berg noted the need for qualitative research to more fully understand the reasoning behind e-cig use in this population (Berg, 2016). Because quantitative methods are most commonly used when studying e-cigs, it is useful to present quantitative data for comparability across studies. However, qualitative research is also useful when a phenomenon is not well understood because these methodologies allow for the illumination of contextual factors and details from the participant that would not otherwise be captured when using quantitative methods alone. Due to the limited data available on e-cig users who were never cigarette smokers, combining these methodologies using a mixed methods approach allows for strengthening of the quantitative results through the support of qualitative responses. Therefore, this study aims to utilize a mixed methods approach in order to gain a more comprehensive understanding of adult e-cig users who were never cigarette smokers with regard to their traditional tobacco product use, reasons for e-cig use and e-cig use patterns as well as to identify topics for future research within this population.