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.

Paul Eelen: Reflections on Life and Work.

This manuscript is part of a special issue to commemorate professor Paul Eelen, who passed away on August 21, 2016. Paul was a clinically oriented scientist, for whom learning principles (Pavlovian or operant) were more than salivary responses and lever presses. His expertise in learning psychology and his enthusiasm to translate this knowledge to clinical practice inspired many inside and outside academia. Several of his original writings were in the Dutch language. Instead of editing a special issue with contributions of colleagues and friends, we decided to translate a selection of his manuscripts to English to allow wide access to his original insights and opinions. Even though the manuscripts were written more than two decades ago, their content is surprisingly contemporary. This introductory article presents a reflection on Paul's career and legacy and introduces the selected manuscripts that are part of this special issue.

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.

From bad to worse: Symbolic equivalence and opposition in fear generalisation.

The present study compared the impact of symbolic equivalence and opposition relations on fear generalisation. In a procedure using nonsense words, some stimuli became symbolically equivalent to an aversively conditioned stimulus while others were symbolically opposite. The generalisation of fear to symbolically related stimuli was then measured using behavioural avoidance, retrospective unconditioned stimulus expectancy and stimulus valence ratings. Equivalence relations facilitated fear generalisation while opposition relations constrained generalisation. The potential clinical implications of symbolic generalisation are discussed.

Blocking in human causal learning is affected by outcome assumptions manipulated through causal structure.

Additivity-related assumptions have been proven to modulate blocking in human causal learning. Typically, these assumptions are manipulated by means of pretraining phases (including exposure to different outcome magnitudes), or through explicit instructions. In two experiments, we used a different approach that involved neither pretraining nor instructional manipulations. Instead, we manipulated the causal structure in which the cues were embedded, thereby appealing directly to the participants' prior knowledge about causal relations and how causes would add up to yield stronger outcomes. Specifically, in our "different-system" condition, the participants should assume that the outcomes would add up, whereas in our "same-system" condition, a ceiling effect would prevent such an assumption. Consistent with our predictions, Experiment 1 showed that, when two cues from separate causal systems were combined, the participants did expect a stronger outcome on compound trials, and blocking was found, whereas when the cues belonged to the same causal system, the participants did not expect a stronger outcome on compound trials, and blocking was not observed. The results were partially replicated in Experiment 2, in which this pattern was found when the cues were tested for the second time. This evidence supports the claim that prior knowledge about the nature of causal relations can affect human causal learning. In addition, the fact that we did not manipulate causal assumptions through pretraining renders the results hard to account for with associative theories of learning.

The inertia of conditioned craving. Does context modulate the effect of counterconditioning?

Previous research (Van Gucht, Baeyens, Vansteenwegen, Hermans, & Beckers, 2010) showed that a cue, initially paired with chocolate consumption, did not cease to elicit craving for chocolate after extinction, but did so after counterconditioning (CC). CC moreover was more effective than extinction in changing evaluations, in disrupting reported cue-elicited expectancy to get to eat chocolate, and in reducing actual consumption. The present research aimed to investigate whether the advantage of CC over extinction in changing acquired craving and liking would survive a change in context after CC. One group of participants received acquisition, CC and a final test all in the same context A (AAA-COUNTER-group). A second group received CC in a different context B (ABA-COUNTER-group). To compare the degree of any renewal after CC to renewal after extinction, a third group received extinction rather than CC in context B (ABA-EXT-group). Data indicate that a context switch after CC/extinction (ABA-groups) results in a return of cue-elicited approach tendencies and US-expectancies that were reduced or reversed after CC/extinction (renewal). As before, acquired liking is reduced only through CC, not by an extinction procedure. After CC in a different context, a return to the original acquisition context did not renew liking.

Narrowing down the conditions for extinction of Pavlovian feature-positive discriminations in humans.

The aim of this study was to delineate the minimal conditions for extinction of Pavlovian modulation in humans. Previous experiments at our lab showed that, after X-- A+/A- acquisition training, X- trials did not extinguish differential X-- A+/A- responding, while X-- A- trials did. Additionally, X-- A- extinction training seemed only to extinguish differential X-- A+/A- responding, while leaving differential responding on a concurrently trained Y [Symbol: see text] B+/B- discrimination intact. It thus seemed that the X-- A+/A- discrimination can only be extinguished by X-- A- extinction trials. (Rescorla, Journal of Experimental Psychology: Animal Behavior Processes 12, 16-24, 1986), on the other hand, found that the minimal conditions for extinction were broader in pigeons: Namely, he found that an acquired X-- A+/A- discrimination could be extinguished by presenting the original feature X in combination with a different target (B) that was minimally trained as an exciter. We thus wanted to examine whether this was also the case in humans. We found that nonreinforced X-- B- presentations did not abolish discriminative X-- A/A responding when target B was a nonreinforced stimulus. Nonreinforced X-- B- trials did extinguish the X-- A+/A- discrimination when target B had previously been trained as a target for modulation (X-- B+/B- or Y [Symbol: see text] B+/B- training) or as a reinforced exciter (B+). Our results thusf parallel and extend those in nonhuman animals (Rescorla, Journal of Experimental Psychology: Animal Behavior Processes 12, 16-24, 1986).

A free software package for a human online-conditioned suppression preparation.

MartiansV2 is both a language syntax in which experiments can be written and an implementation of this syntax in a runtime application that, when fed a valid experiment text file, will execute the given experiment. It is based on the original Martians preparation, which has proven a valuable tool for assessing human online-conditioned suppression performance through research on a wide array of learning phenomena. This article can be read as a manual, both for using the Martians paradigm in general and for getting started with MartiansV2.

Transitions from avoidance: Reinforcing competing behaviours reduces generalised avoidance in new contexts.

Generalised avoidance behaviours are a common diagnostic feature of anxiety-related disorders and a barrier to affecting changes in anxiety during therapy. However, strategies to mitigate generalised avoidance are under-investigated. Even less attention is given to reducing the category-based generalisation of avoidance. We therefore investigated the potential of an operant-based approach. Specifically, it was examined whether reinforcing competing (non-avoidance) behaviours to threat-predictive cues would interfere with the expression of generalised avoidance. Using a matching-to-sample task, artificial stimulus categories were established using physically dissimilar nonsense shapes. A member of one category (conditioned stimulus; CS1) was then associated with an aversive outcome in an Acquisition context, unless an avoidance response was made. Next, competing behaviours were reinforced in response to the CS1 in new contexts. Finally, we tested for the generalisation of avoidance to another member of the stimulus category (generalisation stimulus; GS1) in both a Novel context and the Acquisition context. The selective generalisation of avoidance to GS1 was observed, but only in the Acquisition context. In the Novel context, the generalisation of avoidance to GSs was significantly reduced. A comparison group (Experiment 2), which did not learn any competing behaviours, avoided GS1 in both contexts. These findings suggest that reinforcing competing behavioural responses to threat-predictive cues can lead to reductions in generalised avoidance. This study is among the first study to demonstrate sustained reductions in generalised avoidance resulting from operant-based protocols, and the clinical and research implications are discussed.

A picture-flavour paradigm for studying complex conditioning processes in food preference learning.

An important route through which food (dis)likes can be acquired is Evaluative Conditioning (EC). A simple and convenient EC procedure for studying food (dis)likes was described by Verhulst et al. [Verhulst, F., Hermans, D., Baeyens, F., Spruyt, A., & Eelen, P. (2006). Determinants and predictive validity of direct and indirect measures of recently acquired food attitudes. Appetite, 46(2), 137-143]. We compared this procedure, in which the conditioned and unconditioned stimulus form a compound, with an adapted version in which they are autonomous stimuli. Self-report and affective priming results indicated strong and comparable EC effects in both procedures. Hence, our adaptation constitutes a good alternative for the original procedure. It moreover allows investigating a broader range of topics in food preference learning.

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.

Concomitant deficits in working memory and fear extinction are functionally dissociated from reduced anxiety in metabotropic glutamate receptor 7-deficient mice.

Metabotropic glutamate receptor 7 (mGluR7), a receptor with a distinct brain distribution and a putative role in anxiety, emotional responding, and spatial working memory, could be an interesting therapeutic target for fear and anxiety disorders. mGluR7-deficient (mGluR7-/-) mice showed essentially normal performance in tests for neuromotor and exploratory activity and passive avoidance learning but prominent anxiolytic behavior in two anxiety tests. They showed a delayed learning curve during the acquisition of the hidden-platform water maze, and three interspersed probe trials indicated that mGluR7-/- mice were slower to acquire spatial information. Working memory in the water maze task and the radial arm maze was impaired in mGluR7-/- mice compared with mGluR7+/+. mGluR7-/- mice also displayed a higher resistance to extinction of fear-elicited response suppression in a conditioned emotional response protocol. In a non-fear-based water maze protocol, mGluR7-/- mice displayed similar delayed extinction. These observed behavioral changes are probably not attributable to changes in AMPA or NMDA receptor function because expression levels of AMPA and NMDA receptors were unaltered. Extinction of conditioned fear is an active and context-dependent form of inhibitory learning and an experimental model for therapeutic fear reduction. It appears to depend on glutamatergic and higher-level brain functions similar to those involved in spatial working memory but functionally dissociated from those that mediate constitutional responses in anxiety tests.

The repeated confrontation with videotapes of spiders in multiple contexts attenuates renewal of fear in spider-anxious students.

In a treatment-analogue experiment, extinction of fear of spiders was investigated in a group of spider-anxious students. Two groups were created: in the single extinction group the extinction trials consisted of repeated presentations of a videotaped spider in one specific location of a house, whereas in the multiple extinction group the trials consisted of videotapes of the same spider in three different locations of a house. Also a control group was included that was exposed to videotapes of the location but without the spider. As reflected in skin conductance responses and self-report data, fear of spiders was significantly reduced in the two extinction groups compared to the control group. Moreover, when the extinction groups were confronted with the videotape of the spider in a new location, the single extinction group did not show generalisation of extinction, whereas the multiple extinction group did. These results corroborate the existing evidence for context dependence of extinction of fear and provide new evidence that the use of multiple contexts during extinction might improve the generalisability of extinction in humans. Implications for exposure therapy are discussed.

Reinstatement of conditioned responses in human differential fear conditioning.

The present study aimed at investigating reinstatement of conditioned responding in human classical conditioning using a differential fear conditioning paradigm. Reinstatement is defined as the return of extinguished conditioned responses due to the experience of one or more unexpected USs. As expected the reinstatement group showed reinstatement of US-expectancy while a similar return of conditioned responses was not present in the control group. In the fear ratings a similar pattern was observed. In addition, and in line with previous findings, we found that the more negative the CS+ remained after extinction, the more return of conditioned responding was observed. Clinical implications and suggestions for further research are discussed.

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.

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.

One-trial overshadowing: Evidence for fast specific fear learning in humans.

Adaptive defensive actions necessitate a fear learning system that is both fast and specific. Fast learning serves to minimize the number of threat confrontations, while specific learning ensures that the acquired fears are tied to threat-relevant cues only. In Pavlovian fear conditioning, fear acquisition is typically studied via repetitive pairings of a single cue with an aversive experience, which is not optimal for the examination of fast specific fear learning. In this study, we adopted the one-trial overshadowing procedure from basic learning research, in which a combination of two visual cues is presented once and paired with an aversive electrical stimulation. Using on-line shock expectancy ratings, skin conductance reactivity and startle reflex modulation as indices of fear learning, we found evidence of strong fear after a single conditioning trial (fast learning) as well as attenuated fear responding when only half of the trained stimulus combination was presented (specific learning). Moreover, specificity of fear responding tended to correlate with levels of state and trait anxiety. These results suggest that one-trial overshadowing can be used as a model to study fast specific fear learning in humans and individual differences therein.