Commentary on Notley et al. : Understanding transitions in the use of nicotine and tobacco products-the value of qualitative longitudinal research.

Abstract

Qualitative longitudinal research is an underused methodology in addiction research, but can provide valuable insights into transitions in the use of addictive substances, including e-cigarettes and tobacco smoking. Uncertainty concerning the efficacy of e-cigarettes as a smoking cessation aid has resulted in an increasing number of longitudinal studies measuring transitions in e-cigarette use and smoking status over time [1-3]. However, quantitative studies are limited in being able to determine what factors prompt individuals to make or maintain changes over time [4]. For this, we need narrative accounts of changes over time in nicotine and tobacco use. The paper by Notley, Ward & Dawkins [5] published in Addiction addresses this gap in the literature by presenting the results of a qualitative longitudinal study with 37 UK e-cigarette users who were using e-cigarettes to quit smoking, interviewing them twice approximately 12 months apart. This research demonstrates the type of insights that can result from qualitative longitudinal research. One key finding was that attitudinal differences about nicotine dependence seemed to influence continued use of e-cigarettes. The study found that those who were still using e-cigarettes and not smoking at 12 months thought long-term use of e-cigarettes was acceptable if it prevented relapse to smoking. However, those who had quit smoking and e-cigarettes (abstainers), and those who had relapsed to smoking, were uncomfortable with maintaining nicotine dependence. This aligns with quantitative research showing that while many e-cigarette users intend to continue using the products as a harm reduction strategy, others see it as a smoking cessation strategy and want to quit [6-8]. In order to identify e-cigarette users at risk of relapse to smoking, it may be helpful for health-care vprofessionals to ask users for their views on long-term nicotine dependence. Notley et al. [5] state that those who wish to quit e-cigarettes will need evidence-based information about how to do this while reducing the risk of relapse to smoking. However, research to inform recommendations for quitting using e-cigarettes is currently very limited. Some e-cigarette users report reducing nicotine concentration over time to reduce nicotine dependence, with the goal of eventually ceasing e-cigarette use [9]. An interesting finding of Notley and colleagues [5] is that some participants in their study who had continued to use e-cigarettes and remain abstinent from smoking had reduced their nicotine concentrations in order to ‘test’ their dependence. The effect of reducing nicotine concentrations over time is unknown, and randomized trials are needed to assess whether this is an effective means of quitting e-cigarette use without relapsing to smoking. A small number of studies have asked e-cigarette users whether they would like support in e-cigarette quit attempts, or whether they have sought such support when making quit attempts. In one survey study, Etter [6] found that of those who intended to quit vaping, 27% thought a health professional could assist them, 33% would visit a ‘vaping cessation service’ and 23% would use nicotine medications. A US survey study [8] found that of those who had attempted to cease e-cigarette use in the last year, 25% sought support from family or friends and 11% sought counselling or self-help materials. They also found that those who had used nicotine replacement therapy or cessation medications recommended their use [8]. The research by Notley et al. [5] also reveals factors that combine to influence trajectories of e-cigarette and tobacco use. Attitudes towards nicotine dependence, feelings of satisfaction with e-cigarettes, social exposure to smoking and vaping and life stressors all influenced individual trajectories. These are the complexities and nuances of individual lives that are difficult to capture using quantitative research. The value of qualitative longitudinal research for the addiction field is that it can explore the development of ‘narrative over time’ [10], and how these narratives are linked to the use of addictive substances. This has long been recognized in the ethnographic tradition of addiction research [11]; however, most qualitative studies in the addiction field remain cross-sectional. There are barriers to conducting qualitative longitudinal research [10]. Collecting and analyzing the data is resource and time intensive. Participant retention is critical due to the smaller sample sizes involved in qualitative research, although Notley et al. [5] demonstrate that very high retention rates are possible for nicotine and tobacco research. It would be of value to continue qualitative longitudinal research over periods longer than 1 year. This could be facilitated by embedding a qualitative component in longitudinal quantitative studies, where a subset of participants are interviewed to increase the depth of the study findings. The research reported by Notley et al. [5] shows that for research on smoking and e-cigarettes, longitudinal qualitative research is feasible and high retention rates are possible. The findings increase our depth of understanding of whether and why people transition between smoking, vaping and becoming nicotine-free. None.