Young people's experiences of addiction to nicotine vaping products: A qualitative analysis from Aotearoa New Zealand.

INTRODUCTION: Young people who use nicotine-containing electronic cigarettes, or 'vapes', risk becoming addicted to these products. While several studies document dependency symptoms, few report in-depth qualitative analyses of addiction. METHODS: We explored experiences of self-reported vaping addiction using in-depth interviews with 22 young people aged 16-20 years who vaped and lived in Aotearoa New Zealand. Our semi-structured interview guide probed participants' early experiences and how they progressed from experimentation to addiction and explored how addiction affected their perceptions and daily routines. We used an inductive reflexive thematic analysis approach to interpret the data. RESULTS: Vaping's pervasiveness piqued participants' curiosity and encouraged trial. Most transitioned from experimentation to addiction within a couple of months; while a minority described a slower progression, nearly all felt irritable, angry or uncomfortable if they had to delay vaping. Intense cravings disrupted school and work routines and dictated how they spent their time. Many deeply regretted vaping and some suffered shame and embarrassment. These participants saw vaping as a threat to the well-being of younger youth, which they tried to shield from addiction. DISCUSSION AND CONCLUSIONS: We go beyond earlier studies by probing the burden vaping comes to represent, offering new insights into young people's everyday experiences of vaping addiction. In addition to informing health promotion campaigns, our findings could inform policy directions. Understanding the speed with which addiction can occur, its impact on daily life, and the considerable regret many felt could help inform a more strategic and sorely needed approach to reducing youth vaping.

Global policy scan of commercial combustible tobacco product retailing regulations by WHO region.

BACKGROUND/AIMS: Regulatory schemes for tobacco retailing help restrict the supply and availability of smoked tobacco products. Tobacco retailer density and the proximity of tobacco outlets to youth spaces, such as schools, are greater in more disadvantaged areas. Exposure to tobacco retailing normalises smoking and increases ease of access, thus increasing smoking uptake and undermining quitting. To inform future policy, we conducted a global scan of combustible tobacco retail regulatory schemes (We use the term schemes to refer to any kind of relevant initiative, policy, regulations or legislation that we found). METHODS: All types of English language records concerning the regulation of commercial tobacco product availability were considered, including peer-reviewed journal articles, key reports and policy documents. The key features of regulatory schemes were documented. In addition, we contacted key informants in different countries and regions for advice on additional sources and undertook targeted searching in regions where we initially found little data. RESULTS/FINDINGS: Although many countries have well-established and comprehensive tobacco control programmes, tobacco retail policy that actively addresses the availability of tobacco is underutilised. Many jurisdictions have implemented a minimum purchase age and restricted point-of-sale advertising and marketing. Other tobacco retailing regulations also included licensing systems with licence fees, caps on licences and restrictions on store location, type and retailer density/proximity. A very small number of jurisdictions have ended tobacco retailing altogether. CONCLUSIONS: At a minimum, policy-makers should implement licensing schemes, licence caps and proximity limits and invest in robust monitoring systems and compliance enforcement. Tobacco products' ubiquity is incompatible with its status as a dangerous addictive substance and does not align with tobacco endgame goals.

Specialist vape store audit reveals poor compliance with new e-cigarette regulations.

AIM: Regulations announced in mid-2023 aimed to reduce youth vaping by curtailing the availability of cheap high-nicotine e-cigarettes (vapes). This study tested compliance with the new regulations for single-use vapes, which came into force on 21 December 2023. METHODS: A 20-year-old "mystery shopper" visited 96% of specialist vape retailers (SVRs) in Wellington, Porirua, Lower Hutt and Upper Hutt (N=74) in January 2024, and observed i) R18 signage, ii) age verification practices, and ii) prices and brands of the cheapest available vaping products. Low-price vapes were purchased and inspected for compliance with new nicotine limits and safety regulations. RESULTS: All but three stores (96%) displayed an R18 sign; however, signage in 29 stores (39%) was suboptimal. Only one store (1.4%) requested age identification (ID) on entry to the R18 premises. In 50% of stores, ID was requested when a purchase was made; however, a third of those retailers proceeded with the sale despite the buyer not providing ID. Single-use vapes remained available for NZ$10 or less in most stores, and reusable starter kits were also widely available for NZ$10-20. Discounted high-nicotine products were sold for as little as NZ$2.50 each. Most low-price products did not comply with the updated regulations. CONCLUSION: Cheap, high-nicotine vaping products remained widely available following the introduction of stricter regulations in December 2023; products for sale included discounted and non-compliant vapes. The majority of SVRs had poor age verification practices. There is an urgent need to clarify rules, increase enforcement efforts and disallow discounting and giveaways of vapes.

Managing Fear Responses: A Qualitative Analysis of Pictorial Warning Labels Five Years Post-Plain Packaging.

INTRODUCTION: Although pictorial warning labels (PWLs) now dominate tobacco packages sold in many countries, few studies have probed how people who smoke respond to the threats presented several years post-plain packaging and larger PWLs. Understanding how people manage the fear and dissonance PWLs arouse, and the strategies they use to rationalize, diminish, and reject risk messages, could inform future PWL design. AIMS AND METHODS: We undertook 27 in-depth interviews with people aged 18 and over (16 female, 8 Maori, and 13 aged ≤35) who smoked roll-your-own tobacco and lived in Aotearoa New Zealand. We probed participants' views on current PWLs and how they responded to these, then asked them to use alternative images and headlines to create new PWLs. We drew on the extended parallel processing model to interpret the data, which we analyzed using a reflexive thematic analysis approach. RESULTS: People who smoke dislike PWLs, which they think reduce them to diseased body parts. While a minority thought existing PWLs were believable and effective, most reported avoiding PWLs by hiding or cognitively blocking them. Participants used diverse counterarguments to diminish PWLs' relevance and impact, and a minority displayed strong reactance. Several suggested developing PWLs that recognized them as whole people rather than patients in waiting, and recommended greater use of testimonials, particularly from people who had successfully become smoke free. CONCLUSIONS: PWLs using more holistic and diverse messages could elicit greater engagement and responsiveness, and motivate cessation more effectively than existing health-oriented warnings. IMPLICATIONS: Our findings suggest existing PWLs, which aim to arouse fear of ill health, could be complemented by warnings that emphasize the benefits of quitting. Continuing to use threat-based PWLs could stimulate greater rationalization and reactance. By contrast, PWLs that aim to illustrate how cessation could benefit people who smoke and their families, rather than instill a fear of disease, could avoid message rejection and counter-argument, and may prove a more powerful way of motivating cessation.

A Qualitative Analysis of How Underage Adolescents Access Nicotine Vaping Products in Aotearoa New Zealand.

INTRODUCTION: Despite policies setting a minimum legal sales age, youth continue to access electronic cigarettes (ECs). Evidence of rising youth vaping prevalence in many countries suggests existing measures have serious loopholes and raise important questions about how youth source vaping products. AIMS AND METHODS: We explored how youth source ECs using in-depth interviews with 30 adolescents aged 16-17 who vaped at least once a month and lived in Aotearoa New Zealand. Our semistructured interview guide probed participants' vaping experiences and how they developed and used social, quasi-commercial, and commercial supply routes to access ECs. We used an inductive reflexive thematic analysis approach to interpret the data. RESULTS: Nearly all participants shared ECs with peers and sharing was the sole access route for some. Many used proxies, often older relatives or people they knew socially, to purchase ECs on their behalf; however, others recruited proxies by approaching previously unknown people they identified on social media. Participants also sourced ECs via quasi-commercial networks that existed within schools and on social media, and some purchased in their own right, usually from smaller retail outlets that did not ask for ID. CONCLUSIONS: Disrupting social supply will be challenging, though reducing ECs' availability, appeal, and affordability could make social supply, including sharing and proxy purchasing, more difficult. Reports that youth purchase ECs from commercial retailers known to waive age verification suggest stronger monitoring and enforcement, along with escalating retailer penalties, are required. IMPLICATIONS: Vaping access routes sit on a continuum from informal, spontaneous sharing to carefully planned commercial purchases. While supply via friends, siblings and other social contacts is an important means of access, nicotine dependence drives some to use riskier access routes, including approaching unknown people to act as proxy purchasers. Evidence young people identify noncompliant retailers suggests policy makers should monitor and enforce existing measures more stringently and consider additional penalties for recidivist underage suppliers. A more comprehensive response that reduces the appeal, addictiveness, affordability, and availability of vaping products would address factors fostering and maintaining youth vaping.

Restricting supply of tobacco products to pharmacies: a scoping review.

OBJECTIVE: We synthesised the published literature on proposals to restrict tobacco supply to pharmacies, covering (1) policy concept/rationale/attempts, (2) policy impact and implementation and (3) policy and research recommendations. DATA SOURCES: We searched eight databases (PubMed, CINAHL, Scopus, Web of Science, Embase, IPA, ProQuest and OATD) for publications with at least an English-language abstract. We searched reference lists of included publications manually. STUDY SELECTION: One author screened all publications, and a second author reviewed a 10% subset. We focused on approaches to restrict the supply of tobacco products to pharmacies, without any restrictions on study design, location, participants or publication date. DATA EXTRACTION: Data extraction adhered to the JBI Scoping Review Methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. DATA SYNTHESIS: We included 18 publications. Among the 13 studies conducted in specific geographical contexts, 8 were from Aotearoa/New Zealand. Most publications (n=8) focused on effectiveness domains, indicating potential reductions in retailer density, smoking prevalence, disease burden, cost and increased opportunities for cessation advice. Seven explored policy acceptability among experts, pharmacists and people who smoke. Publications noted that pharmacy-only supply aligns with other programmes involving pharmacists, such as needle exchange programmes, but conflicts with efforts to phase out tobacco sales from the US and Canadian pharmacies. CONCLUSIONS: Progress in tobacco retailing policy (eg, licensing, retailer incentives) and research (eg, assessment of policy equity and durability, application in other geographical contexts) are needed before a pharmacy-only tobacco supply model would be feasible.

Nicotine beliefs and perceptions of low nicotine labels and mitigating statements among people who do and do not smoke: a cross-sectional study from Aotearoa New Zealand.

BACKGROUND: Aotearoa New Zealand proposed a new maximum nicotine content of 0.8 mg/g for smoked tobacco products, although the new government plans to repeal this legislation. Requiring 'Very low nicotine' (VLN) messages on cigarettes meeting this standard may reinforce misperceptions that they are less harmful than cigarettes currently sold. METHODS: To explore knowledge of nicotine and very low nicotine cigarettes (VLNCs), and perceptions of cigarette packs featuring different low nicotine messages (eg, 'Very low nicotine') and mitigating statements (eg, 'No cigarettes are safe'), we surveyed 354 people who smoked, 142 who formerly smoked, and 214 people who had never smoked regularly. RESULTS: Around half of all respondents believed VLNCs were less harmful than regular cigarettes and around two-thirds incorrectly thought nicotine causes most of the related health problems resulting from smoking. Nearly a third thought VLNCs would be less harmful than regular cigarettes; 34% believed they would be just as harmful. Mitigating statements did not affect perceptions of people who smoked, although people who formerly, or who had never smoked regularly, perceived mitigating statements referring to poisons and cancer as significantly more likely than the VLN message to discourage smoking. CONCLUSIONS: Misunderstanding of VLNCs as less harmful than regular cigarettes is widespread; VLN messages may reinforce this misperception, which mitigating statements did not correct among people who smoke. As an alternative to VLN messages, policy makers could consider introducing VLNCs on a specified date and developing public information campaigns; these measures would avoid phase-in confusion and obviate the need for VLN messaging.

How do people who smoke perceive a tobacco retail outlet reduction policy in Aotearoa New Zealand? A qualitative analysis.

BACKGROUND: Aotearoa New Zealand plans to greatly reduce tobacco retail outlets, which are concentrated in areas of higher deprivation and perpetuate health inequities caused by smoking and borne particularly by Maori. However, we lack in-depth analyses of how this measure could affect people who smoke. METHODS: We undertook in-depth interviews with 24 adults from two urban areas who smoke. We used a novel interactive mapping approach to examine participants' current retail outlets and their views on a scenario where very few outlets would sell tobacco. To inform policy implementation, we probed participants' anticipated responses and explored the measure's wider implications, including unintended impacts. We used qualitative description to interpret the data. RESULTS: Most participants anticipated accommodating the changes easily, by using alternative outlets or bulk-purchasing tobacco; however, they felt others would face access problems and increased costs, and greater stress. They thought the policy would spur quit attempts, reduce relapse among people who had quit and protect young people from smoking uptake, and expected more people to switch to alternative nicotine products. However, most foresaw unintended social outcomes, such as increased crime and reduced viability of local businesses. CONCLUSIONS: Many participants hoped to become smoke-free and thought retail reduction measures would prompt quit attempts and reduce relapse. Adopting a holistic well-being perspective, such as those developed by Maori, could address concerns about unintended adverse outcomes and provide comprehensive support to people who smoke as they adjust to a fundamental change in tobacco availability.

Regulating flavours and flavour delivery technologies: an analysis of menthol cigarettes and RYO tobacco in Aotearoa New Zealand.

INTRODUCTION: Menthol facilitates smoking initiation among young people, enhances nicotine's addictiveness and fosters the false belief that menthol products are safer. As a result, several countries have banned use of menthol as a characterising flavour. Aotearoa New Zealand (NZ) could disallow menthol-flavoured cigarettes as part of its endgame legislation; however, little is known about the NZ menthol market. METHODS: To examine the NZ menthol market, we analysed tobacco company returns to the Ministry of Health from 2010 to 2021. We calculated the market share of menthol cigarettes as a percentage of total cigarettes released for sale, estimated capsule cigarettes' market share as a percentage of total cigarette released for sale and menthol released for sale, and calculated menthol roll-your-own (RYO) tobacco released for sale as a percentage of total RYO released. RESULTS: Menthol brands accounted for a relatively small but nonetheless sizeable proportion of NZ's tobacco market and in 2021 constituted 13% of NZ's factory made cigarette market and 7% of the RYO market, representing 161 million cigarettes and 25 tonnes of RYO. The introduction of capsule technologies using menthol flavours corresponded with a rise in menthol sales among factory made cigarettes. CONCLUSIONS: Capsule technologies using menthol flavours work synergistically to enhance the appeal of smoking and appear likely to encourage experimentation among non-smoking young people. Comprehensive policy that regulates menthol flavours and innovations used to deliver flavour sensations will support tobacco endgame goals in NZ and could inform policy in other countries.

New Zealand community pharmacists' perspectives on supplying smoked tobacco as an endgame initiative: a qualitative analysis.

INTRODUCTION: Tobacco endgame strategies often include measures to reduce tobacco availability by decreasing retailer numbers. Recently, some US pharmacies have delisted tobacco, though overall retailer numbers have not reduced markedly. Paradoxically, others have suggested limiting tobacco sales to pharmacies, to reduce supply and support cessation. We explored how pharmacists from Aotearoa New Zealand, a country planning to reduce tobacco supply, perceived supplying tobacco. METHODS: We undertook in-depth interviews with 16 pharmacists from Otepoti Dunedin; most served more deprived communities with higher smoking prevalence. We probed participants' views on supplying tobacco, explored factors that could limit implementation of this policy, and analysed their ethical positions. We used qualitative description to analyse data on limiting factors and reflexive thematic analysis to interpret the ethical arguments adduced. RESULTS: Most participants noted time, space and safety concerns, and some had strong moral objections to supplying tobacco. These included concerns that supplying tobacco would contradict their duty not to harm patients, reduce them to sales assistants, undermine their role as health experts, and tarnish their profession. A minority focused on the potential benefits of a pharmacy supply measure, which they thought would use and extend their skills, and improve community well-being. CONCLUSIONS: Policy-makers will likely encounter strongly expressed opposition if they attempt to introduce a pharmacy supply measure as an initial component of a retail reduction strategy. However, as smoking prevalence falls, adopting a health-promoting supply model, using pharmacies that chose to participate, would become more feasible and potentially enhance community outreach and cessation support.

Smoking, vaping and drinking: A qualitative analysis of Aotearoa New Zealand young adults who tried e-cigarettes to stop smoking tobacco.

BACKGROUND AND AIM: Social practices such as smoking-drinking co-use often go 'hand-in-hand', linked by the coordination of materials, skills and meanings. However, the experience of using e-cigarettes while drinking among people who smoke (and drink) remains underexplored. We used social practice theory to show how smoking, vaping and drinking intersect and to explain how vaping created two new social practices among people who tried e-cigarettes to stop smoking: 'vaping-drinking' co-use and 'smoking-vaping-drinking' poly-use. METHODS: We conducted five in-depth interviews over 18-24 weeks during 2018-19, with each of nine Aotearoa New Zealand young adults aged 20-29 years. Participants smoked daily, did not regularly use e-cigarettes at entry and wished to try vaping to stop smoking. We analysed participants' reports of smoking or vaping while drinking using thematic analysis. RESULTS: Individual participants reported both co-use and poly-use occasions throughout the study. Vaping-drinking co-use arose from practice 'replacement' processes, where vaping fully substituted smoking. Smoking-vaping-drinking poly-use arose from 'adjacency' processes where vaping complemented smoking. Participants used both processes flexibly over time, which required new skills in material, temporal, pleasure and social coordination to try to recreate valued meanings of comfort, security and communality associated with well-established smoking-drinking practices. Unsuccessful coordination attempts maintained smoking-drinking co-use. CONCLUSION: Among Aotearoa New Zealand young adult smokers who want to use vaping to stop smoking, drinking occasions may help to maintain existing smoking-drinking practices and facilitate the development of vaping-drinking co-use and smoking-vaping-drinking poly-use practices, potentially prolonging individuals' exposure to smoking.

A narrative analysis of a tobacco industry campaign to disrupt Aotearoa New Zealand's endgame policies.

BACKGROUND: Aotearoa New Zealand passed world-leading legislation to implement tobacco endgame policies, including greatly reducing the number of tobacco retailers. British American Tobacco New Zealand and Imperial Brands Australasia tried to undermine this policy via the 'Save Our Stores' (SOS) campaign, which purportedly represented small convenience store owners' interests. METHODS: We used the Policy Dystopia Model as a framework to review discursive and instrumental strategies employed in the SOS campaign. Specifically, we critically analysed the arguments, narratives and frames employed in the campaign. RESULTS: Most SOS arguments drew on discursive strategies that emphasised unanticipated costs to the economy and society, and presented a near-apocalyptic future. Adverse outcomes included economic mayhem, thriving illicit trade, increased violent crime, fewer police, and heavier individual tax burdens. The campaign framed the government as an authoritarian legislator with misplaced priorities and used disinformation to bolster these claims. We identified a new normalisation narrative used to present very low nicotine cigarettes (VLNCs) as experimental and, by implication, risky. A metanarrative of lawlessness and decreased public safety connected the different claims. CONCLUSION: To address the existential challenges they face, tobacco companies used several discursive strategies to oppose the retailer reduction and VLNC policies. Our findings could inform counterarguments, and help international policymakers and advocates anticipate opposition they may encounter when introducing endgame measures, such as reducing tobacco availability.

How do underage youth access e-cigarettes in settings with minimum age sales restriction laws? A scoping review.

BACKGROUND: Despite measures to reduce young people's access to electronic cigarettes (ECs), or "vapes", many countries have recorded rising youth vaping prevalence. We summarised studies documenting how underage youth in countries with minimum age sales restrictions (or where sales are banned) report accessing ECs, and outline research and policy implications. METHODS: We undertook a focused literature search across multiple databases to identify relevant English-language studies reporting on primary research (quantitative and qualitative) and EC access sources among underage youth. RESULTS: Social sourcing was the most prevalent EC access route, relative to commercial or other avenues; however, social sourcing dynamics (i.e., who is involved in supplying product and why) remain poorly understood, especially with regard to proxy purchasing. While less prevalent, in-person retail purchasing (mainly from vape shops) persists among this age group, and appears far more common than online purchasing. CONCLUSIONS: Further research examining how social supply routes operate, including interaction and power dynamics, is crucial to reducing youth vaping. Given widespread access via schools and during social activities and events, exploring how supply routes operate and evolve in these settings should be prioritized. Inadequate compliance with existing sales regulations suggest greater national and local policy enforcement, including fines and licence confiscation for selling to minors, is required at the retailer level.

New Zealand adolescents' responses to plain packaging and new pictorial warning labels: Repeat cross-sectional survey analysis.

OBJECTIVE: This article aims to examine the impact on adolescents of New Zealand's 2018 legislation introducing plain (standardised) packaging and enhanced pictorial warning labels (PWLs). METHODS: Data came from Year 10 (14-15 years old) students in the 2016 (2,884 participants) and 2018 (2,689 participants) Youth Insights Surveys conducted 2 years before and immediately after legislation implementation. We used binary and ordinal logistic regression to investigate changes in brand awareness and preference, brand and pack appeal, and PWL salience and impact. RESULTS: The proportion of all participants, and ever, ex/experimental and current smokers who could name one or five tobacco product brands decreased in 2018. There was a modest and nonstatistically significant decrease in the proportion of current smokers citing brand name and image, and a larger decrease in the proportion stating perceived harm to health, influenced preferred brand choice. Having a preferred brand among current smokers and pack appeal, and PWL salience and impact among ex/experimental and current smokers were largely unchanged. CONCLUSIONS: We found preliminary evidence that plain packaging and enhanced PWLs reduced tobacco brand awareness and salience, and misperceptions about tobacco brand harmfulness. Data collection occurred shortly after implementation. Additional studies are required to assess longer term impacts of these interventions. PUBLIC HEALTH IMPLICATIONS: The findings complement existing evidence documenting the impact of plain packaging and PWLs on adolescents. Given limitations due to the proximity of the 2018 survey to legislation implementation, further studies with longer follow-up are required.

Perceptions of Illicit Tobacco Sources Following a Proposed Reduction in Tobacco Availability: A Qualitative Analysis of New Zealanders Who Smoke.

INTRODUCTION: Tobacco companies claim that substantially reducing tobacco retail outlets in Aotearoa New Zealand will increase illicit tobacco trade and crime. However, we know little about whether people who smoke anticipate using illicit tobacco once this measure is implemented. Exploring current illicit tobacco use and expected market development would clarify the likely scale of this potential problem. AIMS AND METHODS: We undertook online in-depth interviews with 24 adults who smoke and explored their experiences of illicit tobacco, perceptions of illicit market growth once legal tobacco became less available, intentions to engage in this market, and potential measures that could curb illicit market development. We interpreted the data using a qualitative descriptive approach. RESULTS: Few participants had purchased illegally imported or stolen tobacco. While most did not know how to access illicit tobacco products, many expected illicit trade and crime would increase, if legal tobacco became difficult to access. While cheaper tobacco appealed to many, most perceived illicit supply routes as unsafe and saw products obtained via these sources as likely to be of poor quality. Few suggested measures to control illicit markets, though a minority called for social reforms to reduce poverty, which they thought fueled illegal practices. CONCLUSIONS: Although illicit trade may appear to threaten new policy initiatives, participants' limited knowledge of these markets and concerns regarding product safety suggest illegal tobacco may pose less of a threat than tobacco companies have claimed. Policy makers should not be deterred from reducing tobacco availability by industry arguments. IMPLICATIONS: Although participants believed illicit trade would increase if the number of tobacco retailers was substantially reduced, few anticipated purchasing illegal tobacco. They viewed supply routes as unsafe and product quality as likely to be low. Industry predictions that illicit tobacco trade will grow if tobacco becomes less available do not reflect how people who smoke expect to engage with these markets and should not deter the introduction of retail reduction measures.

A Qualitative Analysis of the Experiences of People Who Resumed Smoking Following Exclusive Electronic Nicotine Delivery Systems Use.

INTRODUCTION: For electronic nicotine delivery systems (ENDS) to reduce harms caused by smoking, people who smoke must be able to switch to exclusive ENDS use without subsequently returning to smoking. Identifying factors prompting a return to smoking among former exclusive ENDS users is crucial, yet few qualitative studies have probed experiences of this process. AIMS AND METHODS: We conducted in-depth, semi-structured interviews with 20 people (seven indigenous Maori and 13 non-Maori) who smoked tobacco at least weekly, had smoked at least 100 cigarettes in their lifetime, and reported using ENDS to stop smoking cigarettes for at least 30 days (ideally, within the preceding 6 months). We explored their experiences of ENDS use, probed critical return-to-smoking settings and triggers, and analyzed strategies that could promote sustained smoking abstinence. We managed data using NVivo12 and used a reflexive thematic analysis approach to interpret the transcripts. RESULTS: We identified three themes that explained participants' experiences. ENDS performed a functional role by mimicking some aspects of smoking. Yet participants experienced ENDS as inauthentic and unsatisfying across physical, social, and affectual domains, including in the most common return-to-smoking situations. Furthermore, fewer constraints on ENDS usage led participants to feel they could perpetuate addiction and risk of harm. CONCLUSIONS: Return to smoking reflected two factors: ENDS' failure to replicate core smoking attributes that remained appealing, and the burden of self-regulation required when using ENDS. Understanding and informing people about the challenges involved in transitioning to ENDS, beyond obtaining sufficient nicotine, could help support informed ENDS use and may potentially prevent people returning to smoking. IMPLICATIONS: Our study extends our understanding of the satisfaction people seek when attempting to transition from smoking to exclusive ENDS use, and how ENDS' failure to replicate that satisfaction, in addition to uncertainty about ENDS-related risks, contributes to smoking resumption. Satisfaction went beyond nicotine delivery, and included affective experiences, maintenance of rituals, rewards, and social connections. Conceptualizing satisfaction more broadly could support a richer understanding of factors that prompt return to smoking. People might manage challenges more effectively if they understood these before attempting to switch from smoking to ENDS, and if they are advised to monitor and regulate their ENDS use. Educational resources and behavioral support could provide more guidance on these points.