Nicotine addiction as a moral problem: Barriers to e-cigarette use for smoking cessation in two working-class areas in Northern England

Frances Thirlway

doi:10.1016/j.socscimed.2019.112498

Abstract

Tobacco use in high-income countries correlates with socio-economic disadvantage, but although switching to electronic cigarettes could be a safer alternative, little is known about barriers to use. Drawing on eighteen months of data collection in two areas of Northern England in 2017/18 including ethnography and interviews with 59 smokers and e-cigarette users, I show that concern about continued nicotine addiction either deterred working-class smokers from switching to e-cigarettes or dictated the conditions of their use. Research participants were unhappy about addiction both as loss of control experienced as moral failure and as neglect of financial responsibilities i.e. role performance failure in relation to family responsibilities, or what I call ‘thrift as care’. They reduced the moral burden of addiction by lowering nicotine content, rejecting pleasure and minimising expenditure. They chose the cheapest possible tobacco, switched from combusted tobacco to cheaper e-cigarettes and bought cheap e-cigarettes and liquids. For working-class smokers, minimising spend on what they perceive negatively as addiction may be a greater moral concern than reducing health risk. I conclude that ensuring that vaping is significantly cheaper than smoking may be key to addressing health inequalities linked to tobacco use.

Highlights

Whilst smoking rates in high-income countries have declined over the past thirty years, they remain high amongst the poorest (West et al, 2019) and contribute significantly to health inequalities (Kulik et al, 2013)
Is the failure of agency linked to addiction necessarily experienced as morally problematic? Flanagan sees it as leading automatically to a sense of personal failure and shame; sub-Saharan African philosophy's account of addiction offending against the life-force suggests this idea has cross-cultural validity beyond western ethicists' Kantian accounts of addiction degrading rationality or autonomy (Metz, 2018)
Social scientists concerned with the social production of addiction theorise the shame of addiction as the internalisation of external stigma (Matthews et al, 2017) or make the Foucauldian argument that claims that addicts' freedom and autonomy are compromised conceal the reality that state institutions disapprove of their choices (Keane, 2002; Reith, 2004; Rooney, 2003; Fraser et al, 2014)

Summary

Introduction

Whilst smoking rates in high-income countries have declined over the past thirty years, they remain high amongst the poorest (West et al, 2019) and contribute significantly to health inequalities (Kulik et al, 2013). Since smokers with lower socio-economic status (SES) consistently score highly on indices of addiction (Reid et al, 2010), it has been hypothesised that they might benefit disproportionately from electronic cigarettes, which administer nicotine, the addictive ingredient of tobacco, in a safer, non-combusted form (Fairchild et al, 2014). This is an example of the harm reduction approach to addiction according to which public health authorities should reduce harm from addictive substances by promoting safer way of taking them (Marlatt, 1996). Unlike NRT, which is designed and marketed as a time-limited smoking cessation tool, the e-cigarette has acquired disruptive status from uncertainty as to whether it is a temporary cessation aid, a long-term harm reduction device or a recreational item (Rooke et al, 2016 p. e62-e63)

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Conclusion