All of us are familiar with the scene: a bunch of teenagers absentmindedly puffing away at mango-flavoured vapers. But are these trendy and colourful gadgets actually more addictive than old-school cancer sticks?
Vaping has exploded in popularity, with over 3 million adult vapers currently in the UK alone (Action on Smoking and Health, 2022). E-cigarettes remain controversial, many people use them as a cessation aid while scientists worry about their role in increasing the risk of smoking among youth. We know that e-cigarettes do not include many harmful chemicals that cigarettes include (Collier, 2017), yet the long-term impacts of e-cigarettes are unknown (Marquez et al., 2021). In the USA, no e-cigarette product has been approved by FDA as a smoking cessation device. Similarly, in the UK, e‑cigarettes are not licensed as medicines but are regulated by the Tobacco and Related Products Regulations (2016). The National Institute for Health and Care Excellence (NICE) recommends providing e-cigarettes as an option for smokers who would like to stop smoking. Nevertheless, more research is needed to determine the safety and effectiveness of e-cigarettes as a smoking cessation aid.
An important issue is whether e-cigarettes cause addiction just like deadly tobacco. Previous research suggests that the risk of addiction, which is typically measured by craving or immediate e-cigarette use after waking, is lower in e-cigarette users compared to smokers (Liu et al., 2017; Strong et al., 2017). However, there are lots of unknowns regarding the relationship between e-cigarettes and dependence.
In this new cross-sectional study, Lohner and colleagues analysed the results of a survey of 832 adults who use e-cigarettes in England to understand perceptions of e-cigarette addiction. Their study explores to what extent e-cigarette users experience dependence, and how this compares to tobacco.
Methods
The researchers conducted a UK-based cross-sectional study. In total, 832 e-cigarette users in England participated in the survey and self-reported their perceived addiction to e-cigarettes and perceived addictiveness in comparison to tobacco cigarettes. The study explored the connections between perceived addiction and signs of addiction, including the time it takes to vape for the first time in the morning, the urge to vape, and nicotine strength, as well as vaping characteristics such as frequency and enjoyment. The authors adjusted their analysis for sociodemographic characteristics, such as age, gender, education and tobacco cigarette smoking status, and conducted sensitivity analyses to control for confounding factors and bias.
Results
Of all participants, 17% reported feeling very addicted to e-cigarettes, while 35% considered e-cigarettes equally addictive as tobacco cigarettes, and just below 6% felt e-cigarettes were more addictive than tobacco cigarettes. The study showed that several factors linked to nicotine addiction also related to feeling very addicted to e-cigarettes. These included vaping right after waking up, getting strong urges to vape, and using high-nicotine e-liquid. Study participants who vaped within 5 minutes of waking were more likely to report feeling very addicted compared to those who waited over an hour before vaping. Similarly, those reporting strong urges to vape had higher odds of feeling very addicted relative to moderate urges. Additionally, liquid nicotine levels had a role in addiction too as people using very high-nicotine e-liquid (>15mg/ml) had higher odds of feeling very addicted compared to those using low or no nicotine. In terms of vaping patterns, using e-cigarettes every day, and getting extreme enjoyment from vaping were also found to be associated with feeling very addicted. When looking at perceived addictiveness relative to smoking tobacco, the use of e-cigarettes within 5 minutes of waking and daily vaping were associated with a higher likelihood of viewing e-cigarettes as equally or more addictive compared to cigarettes. But most signs of addiction weren’t really tied to thinking e-cigarettes are more addictive than smoking. The only exceptions were vaping right after waking up and vaping daily, which related somewhat to perceiving e-cigarettes as very addictive. Overall, this study found that e-cigarettes seem to have some addictive potential, but most users don’t consider them as addictive as tobacco cigarettes.
Conclusions
The study shows that while some e-cigarette users show signs of dependence, the overall prevalence of perceived addiction and markers of addiction is lower. It appears that e-cigarettes can be addictive, although perhaps not to the same extent as tobacco cigarettes. However, there is still a risk of dependence for some users. It may be useful to keep track of nicotine consumption in order to spot those who are developing an addiction. The study also shows that markers of addiction to e-cigarettes and the perceived addiction were consistent. The causal link between e-cigarettes and addiction is muddied by previous or current tobacco addiction.
Implications for Practice
This study provides further evidence for providing e-cigarettes as a cessation aid for adult smokers as many users perceive e-cigarettes as less addictive than smoking. Since tobacco smoking is more harmful than e-cigarettes, the small risk of developing dependence for a subset of e-cigarette users found in this study seems negligible. Monitoring markers of dependence like time to first use, nicotine levels, and enjoyment may help identify problematic use. Therefore, clinicians should monitor and assess patterns of e-cigarette use and nicotine addiction in patients, especially in individuals showing signs of heavy e-cigarette use, strong urges to vape, and early morning vaping.
