Vaping during the COVID-19 lockdown period in Belgium.

BACKGROUND: Due to the Corona Virus Disease 2019 (COVID-19), the Belgian government set out a range of measures to prevent the spread of the virus. One measure included closing all non-food shops, including vape shops. METHODS: A retrospective online questionnaire was used to investigate the impact of closing the vape shops on the vaping and/or smoking behavior of current vapers. RESULTS: The sample (n = 202) reached consisted of 70% exclusive vapers, 29% dual users and 1% no-product users. Over half (55%, 112/202) of participants needed to buy e-liquid during the lockdown, with a small majority being able to buy e-liquids - mostly with their usual nicotine concentrations, flavor or brand -, but as much as 39% (44/112) of them ran out of e-liquid. Those buying e-liquid mainly did so by making purchases via foreign online webshops. A similar pattern was observed with respect to purchasing hardware, with about half (47%, 95/202) of participants reporting hardware availability and with a small majority (53%, 107/202) reporting hardware unavailability. Of those indicating that hardware was not available, 38% (41/107) ran out of a properly functioning e-cigarette. A non-trivial minority had to consume e-liquids with another nicotine concentration, flavor or brand than usual. One seventh of exclusive vapers before lockdown relapsed partly or completely to smoking during the lockdown. The main reasons for changing vaping and/or smoking behavior included the unavailability of e-liquid with nicotine, the unavailability of hardware, and stress/worries about COVID-19. CONCLUSIONS: The majority of vapers succeeded in maintaining their vaping behavior as usual, highly likely due to (illegally) buying consumables online. Nevertheless, for a minority the lockdown period resulted in unintended consequences and these vapers relapsed (completely) to smoking. Even during periods of lockdown, smokers and vapers should be able to purchase low(er)-risk alternatives to smoking, for example e-cigarettes.

Electronic cigarettes in standard smoking cessation treatment by tobacco counselors in Flanders: E-cigarette users show similar if not higher quit rates as those using commonly recommended smoking cessation aids.

BACKGROUND: This interventional-cohort study tried to answer if people who smoke and choose an e-cigarette in the context of smoking cessation treatment by tobacco counselors in Flanders are achieving smoking abstinence and how they compare to clients who opt for commonly recommended (or no) aids (nicotine replacement therapy, smoking cessation medication). METHODS: Participants were recruited by tobacco counselors. They followed smoking cessation treatment (in group) for 2 months. At several times during treatment and 7 months after quit date, participants were asked to fill out questionnaires and to perform eCO measurements. RESULTS: One third of all participants (n = 244) achieved smoking abstinence 7 months after the quit date, with e-cigarette users having higher chances to be smoking abstinent at the final session compared to NRT users. Point prevalence abstinence rates across all follow-up measurements, however, as well as continuous and prolonged smoking abstinence, were similar in e-cigarette users and in clients having chosen a commonly recommended (or no) smoking cessation aid. No differences were obtained between smoking cessation aids with respect to product use and experiences. CONCLUSIONS: People who smoke and choose e-cigarettes in the context of smoking cessation treatment by tobacco counselors show similar if not higher smoking cessation rates compared to those choosing other evidence-based (or no) smoking cessation aids.

When Less is More: Vaping Low-Nicotine vs. High-Nicotine E-Liquid is Compensated by Increased Wattage and Higher Liquid Consumption.

(1) Background: Previous research (Van Gucht, Adriaens, and Baeyens, 2017) showed that almost all (99%) of the 203 surveyed customers of a Dutch online vape shop had a history of smoking before they had started using an e-cigarette. Almost all were daily vapers who used on average 20 mL e-liquid per week, with an average nicotine concentration of 10 mg/mL. In the current study, we wanted to investigate certain evolutions with regard to technical aspects of vaping behaviour, such as wattage, the volume of e-liquid used and nicotine concentration. In recent years, much more powerful devices have become widely available, e-liquids with very low nicotine concentrations have become the rule rather than the exception in the market supply, and the legislation has been adjusted, including a restriction on maximum nicotine concentrations to 20 mg/mL. (2) Methods: Customers (n = 150) from the same Dutch online vape shop were contacted (to allow a historical comparison), as well as 274 visitors from the Facebook group "Belgian Vape Bond" to compare between groups from two different geographies and/or vaping cultures. (3) Results: Most results were in line with earlier findings: Almost all surveyed vapers were (ex-)smokers, had started (80%) vaping to quit smoking and reported similar positive effects of having switched from smoking to vaping (e.g., improved health). A striking observation, however, was that whereas customers of the Dutch online vape shop used e-liquids with a similar nicotine concentration as that observed previously, the Belgian vapers used e-liquids with a significantly lower nicotine concentration but consumed much more of it. The resulting intake of the total quantity of nicotine did not differ between groups. (4) Conclusions: Among vapers, different vaping typologies may exist, depending on subcultural and/or geographic parameters. As a consequence of choosing low nicotine concentrations and consuming more e-liquid, the Belgian vapers may have a greater potential to expose themselves to larger quantities of harmful or potentially harmful constituents (HPHCs) released during vaping.

IQOSTM vs. e-Cigarette vs. Tobacco Cigarette: A Direct Comparison of Short-Term Effects after Overnight-Abstinence.

Introduction: Research from Philip Morris International's science division on its Heat-not-Burn product IQOSTM focused on its chemical, toxicological, clinical, and behavioral aspects. Independent research on the experiences and behavioral aspects of using IQOSTM, and how it compares to e-cigarettes, is largely lacking. The current randomized, cross-over behavioral trial tried to bridge the latter gaps. Methods: Participants (n = 30) came to the lab on three consecutive days after being overnight smoking abstinent. During each session, participants used one of three products (cigarette, e-cigarette, or IQOSTM) for five minutes. Exhaled CO (eCO) measurements and questionnaires were repeatedly administered throughout the session. Results: Smoking a cigarette for five minutes resulted in a significant increase of eCO, whereas using an IQOSTM resulted in a small but reliable increase (0.3 ppm). Vaping did not affect eCO. Cigarette craving reduced significantly after product use, with the decline being stronger for smoking than for e-cigarettes or IQOSTM. Withdrawal symptoms declined immediately after smoking or using IQOSTM, and with some delay after vaping. IQOSTM scored higher in terms of subjective reward/satisfaction and was slightly preferred to the e-cigarette. Discussion: Short-term use of IQOSTM has a minimal impact on eCO, is equally effective in reducing cigarette craving and withdrawal symptoms as an e-cigarette, and is slightly preferred.

About One in Five Novice Vapers Buying Their First E-Cigarette in a Vape Shop Are Smoking Abstinent after Six Months.

Background: E-cigarette use is rising with the majority of vapers purchasing their e-cigarettes in vape shops. We investigated the smoking/vaping trajectories and quit-smoking success rates of smokers deciding to start vaping for the first time and buying their e-cigarette in brick-and-mortar vape shops in Flanders. Methods: Participants filled out questionnaires assessing smoking/vaping behaviour at three moments (intake, after three and six months) and smoking status was biochemically verified using eCO measurements. Results: Participants (n = 71) were regular smokers (MeCO-intake = 22 ppm), half of whom reported a motivation to quit smoking in the near future. Participants bought 3rd/4th generation e-cigarettes and e-liquid with a nicotine concentration averaging 7 mg/mL. A smoking reduction of 53% (17 cigarettes per day (CPD) at intake to 8 CPD after six months) was observed, whereas eCO decreased to 15 ppm. Eighteen percent of participants had quit smoking completely (eCO = 2 ppm), another 25% had at least halved CPD, whereas 57% had failed to reduce CPD by at least 50% (including 13% lost to follow-up). Quitters consumed more e-liquid than reducers and those who continued to smoke. Conclusions: Around one in five smoking customers buying their first e-cigarette in a brick-and-mortar vape shop had quit smoking completely after six months.

Online Vape Shop Customers Who Use E-Cigarettes Report Abstinence from Smoking and Improved Quality of Life, But a Substantial Minority Still Have Vaping-Related Health Concerns.

(1) Background: Characteristics and usage patterns of vapers (e-cigarette users) have mainly been studied in web-based convenience samples or in visitors of brick-and-mortar vape shops. We extended this by targeting customers of one particular online vape shop in the Netherlands; (2) Methods: Customers were questioned on their smoking history, current smoking and vaping status, reasons for vaping, perceived harmfulness, and potential health changes due to vaping; (3) Results: Almost everyone (99%, 95% CI 0.96, 1.00) smoked before they started vaping. A great majority agreed that unlike with other smoking-cessation aids, they could quit smoking (81%, 95% CI 0.79, 0.90) due to vaping. Almost all customers were regular vapers (93.6%, 95% CI 0.89, 0.96) who used state-of-the-art open system devices without modifications and e-liquid with 10 mg/mL nicotine on average. Vapers reported using e-cigs to quit smoking, because e-cigs are healthier, and for financial reasons. The majority (52.6%, 95% CI 0.46, 0.60) perceived vaping as not that harmful to not harmful at all, but one fifth (21.8%, 95% CI 0.16, 0.28) believed vaping to be harmful. More than half (57.8%, 95% CI 0.50, 0.65) reported gaining more pleasure from vaping than from smoking. A substantial majority (84.2%, 95% CI 0.78, 0.89) agreed that their health had improved since they started vaping; (4) Conclusions: Findings are similar to those obtained in other vape shop studies, but also to the results of convenience samples of less-well-defined populations.

The Importance of Conditioned Stimuli in Cigarette and E-Cigarette Craving Reduction by E-Cigarettes.

This study examined the impact of four variables pertaining to the use of e-cigarettes (e-cigs) on cravings for tobacco cigarettes and for e-cigs after an overnight abstinence period. The four variables were the nicotine level, the sensorimotor component, the visual aspect, and the aroma of the e-cig. In an experimental study, 81 participants without prior vaping experience first got acquainted with using e-cigs in a one-week tryout period, after which they participated in a lab session assessing the effect of five minutes of vaping following an abstinence period of 12 h. A mixed-effects model clearly showed the importance of nicotine in craving reduction. However, also non-nicotine factors, in particular the sensorimotor component, were shown to contribute to craving reduction. Handling cues interacted with the level (presence/absence) of nicotine: it was only when the standard hand-to-mouth action cues were omitted that the craving reducing effects of nicotine were observed. Effects of aroma or visual cues were not observed, or weak and difficult to interpret, respectively.

Differences between Dual Users and Switchers Center around Vaping Behavior and Its Experiences Rather than Beliefs and Attitudes.

(1) Background: Many smokers completely switch to vaping (switchers), whereas others use e-cigarettes (e-cigs) alongside tobacco cigarettes (dual users). To the extent that dual users substantially lower the number of cigarettes, they will reduce health risks from smoking. However, from a medical point of view, exclusive vaping is preferable to dual use; (2) Methods: Using an online questionnaire we assessed behavioral, cognitive and attitudinal aspects of e-cig use in smoking and ex-smoking vapers; (3) Results: Our sample consisted of 19% dual users and 81% switchers. Before e-cig initiation, both groups smoked on average 22 cigarettes per day (CPD). After e-cig initiation, dual users decreased tobacco consumption by 82% and were low-to-moderately cigarette dependent. Both groups had been vaping for on average 22 months, were highly e-cig dependent, used state-of-the-art e-cigs, nicotine concentrations of 4-8 mg/mL and often flavors other than tobacco. Dual users used substantially less e-liquid per week than switchers but reported a similar number of puffs/day, experienced less e-cig efficacy, more practical problems, more negative and less positive consequences, and endorsed smoking reduction (rather than quitting) as a more important reason to start vaping. For both groups, e-cig risk perception was low and little stigmatization was experienced. Dual users preferred tobacco cigarettes in stressful situations and when rapid nicotine uptake is required. E-cigs were preferred where cigarettes are prohibited and to reduce second-hand smoke; (4) Conclusions: Differences between dual users and switchers center around variables proximal to the vaping behavior and its experienced effects rather than hinging on more general vaping-related beliefs and attitudes.

Harmful effects from one puff of shisha-pen vapor: methodological and interpretational problems in the risk assessment analysis.

With this letter we express our concerns about the applicability of the proposed Margin of Exposure analysis as a method of risk assessment for propylene glycol and glycerol exposure from a shisha-pen type electronic cigarette. The studies used to determine the Margin of Exposure were evaluating the effects in humans or animals of continuous exposure to these chemicals in every single breath, whereas electronic cigarettes are used intermittently by consumers, resulting in lower and discontinuous exposure. Moreover, the authors make no clear distinction between irritation and harm, neither do they discuss the effects of exposure compared to continuous smoking.

Health professionals in Flanders perceive the potential health risks of vaping as lower than those of smoking but do not recommend using e-cigarettes to their smoking patients.

BACKGROUND: Many misperceptions of both risks and opportunities of e-cigarettes (e-cigs) exist among the general population and among physicians, although e-cigs could be a valuable harm reduction tool for current smokers. METHODS: Two groups in Flanders, namely general practitioners (GPs; family doctors) and tobacco counselors filled out an online questionnaire with regard to their attitudes and risk perceptions concerning e-cigs. Statements included were on the safety and the addictive properties of e-cigs in absolute terms, whereas other items compared e-cigs with regular tobacco cigarettes. Statements about possible "gateway" and "renormalization" effects, selling to minors, and use in public places and on the potential of e-cigs as a smoking cessation aid were also included. Respondents were also asked for the rate at which their patients asked information about e-cigs, if they would recommend e-cigs to their smoking patients, and whether they had information brochures on e-cigs. RESULTS: About 70 % believed that e-cigs are harmful to vapers, and about half to two thirds believed that e-cigs are carcinogenic, increase cardiovascular risk, and increase the risk of chronic lung disease. Also, a substantial minority incorrectly believed these risks to be no less than those resulting from regular smoking. Ten to almost 20 % disagreed that e-cigs are healthier and represent less risk for the main serious smoking-related diseases than conventional cigarettes. More than half of the respondents disagreed that e-cigs are an effective smoking cessation aid. None (0 %) offered the strongest level of agreement for recommending e-cigs to their clients/patients, but GPs agreed to a lesser degree a bit more often than tobacco counselors. Almost none had information leaflets for potentially interested patients. Finally, the majority of our sample also believed that e-cigs will cause renormalization of smoking and that e-cigs will lead to an uptake of conventional smoking and disagreed with allowing vaping in enclosed public places. CONCLUSIONS: Health professionals in Flanders perceive the potential health risks of vaping as lower than those of smoking but do not recommend using e-cigs to their smoking patients.

Effectiveness of the electronic cigarette: An eight-week Flemish study with six-month follow-up on smoking reduction, craving and experienced benefits and complaints.

BACKGROUND: Smoking reduction remains a pivotal issue in public health policy, but quit rates obtained with traditional quit-smoking therapies remain disappointingly low. Tobacco Harm Reduction (THR), aiming at less harmful ways of consuming nicotine, may provide a more effective alternative. One promising candidate for THR are electronic cigarettes (e-cigs). The aim of this study was to investigate the efficacy of second-generation e-cigs both in terms of acute craving-reduction in the lab and in terms of smoking reduction and experienced benefits/complaints in an eight-month Randomized Controlled Trial (RCT). DESIGN: RCT with three arms. METHODS: Participants (N = 48) unwilling to quit smoking were randomized into two e-cig groups and one control group. During three lab sessions (over two months) participants, who had been abstinent for four hours, vaped/smoked for five minutes, after which we monitored the effect on craving and withdrawal symptoms. eCO and saliva cotinine levels were also measured. In between lab sessions, participants in the e-cig groups could use e-cigs or smoke ad libitum, whereas the control group could only smoke. After the lab sessions, the control group also received an e-cig. The RCT included several questionnaires, which repeatedly monitored the effect of ad libitum e-cig use on the use of tobacco cigarettes and the experienced benefits/complaints up to six months after the last lab session. RESULTS: From the first lab session on, e-cig use after four hours of abstinence resulted in a reduction in cigarette craving which was of the same magnitude as when a cigarette was smoked, while eCO was unaffected. After two months, we observed that 34% of the e-cig groups had stopped smoking tobacco cigarettes, versus 0% of the control group. After five months, the e-cig groups demonstrated a total quit-rate of 37%, whereas the control group showed a quit rate of 38% three months after initiating e-cig use. At the end of the eight-month study, 19% of the e-cig groups and 25% of the control group were totally abstinent from smoking, while an overall reduction of 60% in the number of cigarettes smoked per day was observed (compared to intake). eCO levels decreased, whereas cotinine levels were the same in all groups at each moment of measurement. Reported benefits far outweighed the reported complaints. CONCLUSION: In a series of controlled lab sessions with e-cig naïve tobacco smokers, second generation e-cigs were shown to be immediately and highly effective in reducing abstinence induced cigarette craving and withdrawal symptoms, while not resulting in increases in eCO. Remarkable (>50 pc) eight-month reductions in, or complete abstinence from tobacco smoking was achieved with the e-cig in almost half (44%) of the participants.