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.

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.

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.

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.

Implicit attitudes towards smoking predict long-term relapse in abstinent smokers.

RATIONALE: It has previously been argued that implicit attitudes toward substance-related cues drive addictive behavior. Nevertheless, it remains an open question whether behavioral markers of implicit attitude activation can be used to predict long-term relapse. OBJECTIVES: The main objective of this study was to examine the relationship between implicit attitudes toward smoking-related cues and long-term relapse in abstaining smokers. METHODS: Implicit attitudes toward smoking-related cues were assessed by means of the Implicit Association Test (IAT) and the evaluative priming task (EPT). Both measures were completed by a group of smokers who volunteered to quit smoking (patient group) and a group of nonsmokers (control group). Participants in the patient group completed these measures twice: once prior to smoking cessation and once after smoking cessation. Relapse was assessed by means of short telephone survey, 6 months after completion of the second test session. RESULTS: EPT scores obtained prior to smoking cessation were related to long-term relapse and correlated with self-reported nicotine dependence as well as daily cigarette consumption. In contrast, none of the behavioral outcome measures were found to correlate with the IAT scores. CONCLUSIONS: These findings corroborate the idea that implicit attitudes toward substance-related cues are critically involved in long-term relapse. A potential explanation for the divergent findings obtained with the IAT and EPT is provided.

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.

The Attitudes to Chocolate Questionnaire. Psychometric properties and relationship with consumption, dieting, disinhibition and thought suppression.

We examined the psychometric properties of the Dutch version of the Attitudes to Chocolate Questionnaire (ACQ), comparing the original three-factor model to a later-suggested two-factor model. We evaluated the construct validity of the ACQ by investigating the associations between the resulting factors and other eating-related questionnaires such as the Three Factor Eating Questionnaire and the Food Thought Suppression Inventory. Finally, we compared the scores on several scales regarding eating behavior between different groups (men versus women, dieters versus non-dieters and cravers versus non-cravers). A confirmatory factor analysis of the Dutch ACQ indicated the best global fit indices for the two-factor model, with the resulting factors being "Negative consequences and Guilt" and "Craving and emotional eating". Both factors were associated with other eating-related dimensions. However, craving seemed to be uniquely associated with the amount of chocolate consumed per week, whereas guilt correlated strongly with restraint. Finally, women scored higher on nearly all scales, but there was no significant gender difference with regard to chocolate consumption. Dieters reported more disinhibition, restraint, food-thought suppression and guilt, but they did not significantly differ from non-dieters with regards to their levels of craving, hunger nor consumption.

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.

Cognitive reactivity to success and failure relate uniquely to manic and depression tendencies and combine in bipolar tendencies.

The present study examined simultaneously the relations between cognitive reactivity to success and failure, on the one hand, and depression, manic, and bipolar tendencies, on the other hand. Participants (161 students) completed measures of success and failure reactivity, current manic and depressive symptoms, and tendencies towards depression, mania, and bipolarity. Results showed that respondents with a greater tendency towards depression evidenced greater (negative) reactivity to failure, whereas those with a greater tendency toward mania evidenced greater (positive) reactivity to success. Depression vulnerability was unrelated to success reactivity, and manic vulnerability was unrelated to failure reactivity. Tendencies toward bipolarity correlated significantly with both failure and success reactivity in a negative and positive manner, respectively. These findings add to the growing body of literature, suggesting that different features or cognitive tendencies are related to depression vulnerability versus manic vulnerability and imply that these "mirrored" cognitive features both form part of vulnerability to bipolar disorder.

Construction and factorial validation of a short form of the Self-Compassion Scale.

The objective of the present study was to construct and validate a short-form version of the Self-Compassion Scale (SCS). Two Dutch samples were used to construct and cross-validate the factorial structure of a 12-item Self-Compassion Scale-Short Form (SCS-SF). The SCS-SF was then validated in a third, English sample. The SCS-SF demonstrated adequate internal consistency (Cronbach's alpha ≥ 0.86 in all samples) and a near-perfect correlation with the long form SCS (r ≥ 0.97 all samples). Confirmatory factor analysis on the SCS-SF supported the same six-factor structure as found in the long form, as well as a single higher-order factor of self-compassion. The SCS-SF thus represents a reliable and valid alternative to the long-form SCS, especially when looking at overall self-compassion scores.

Counterconditioning reduces cue-induced craving and actual cue-elicited consumption.

Cue-induced craving is not easily reduced by an extinction or exposure procedure and may constitute an important route toward relapse in addictive behavior after treatment. In the present study, we investigated the effectiveness of counterconditioning as an alternative procedure to reduce cue-induced craving, in a nonclinical population. We found that a cue, initially paired with chocolate consumption, did not cease to elicit craving for chocolate after extinction (repeated presentation of the cue without chocolate consumption), but did so after counterconditioning (repeated pairing of the cue with consumption of a highly disliked liquid, Polysorbate 20). This effect persisted after 1 week. Counterconditioning moreover was more effective than extinction in disrupting reported expectancy to get to eat chocolate, and also appeared to be more effective in reducing actual cue-elicited chocolate consumption. These results suggest that counterconditioning may be more promising than cue exposure for the prevention of relapse in addictive behavior.

The Dutch version of the Behavioral Activation for Depression Scale (BADS): psychometric properties and factor structure.

In a community sample of 402 respondents, the authors examined the psychometric properties of the Dutch version of the Behavioral Activation for Depression Scale (BADS; Kanter, Mulick, Busch, Berlin, & Martell, 2006). Results of confirmatory factor analysis supported the original 4-factor structure, providing the following subscales: Activation, Avoidance/Rumination, Work/School Impairment, and Social Impairment. All subscales showed adequate internal consistency, evidence of convergent validity with concurrent measures of depressive symptoms, rumination, psychological flexibility, and avoidance behavior, and evidence of differential validity between currently, formerly, and never depressed respondents.

Smoking behavior in context: where and when do people smoke?

Cue-reactivity research in humans has primarily focused on proximal cues, but little is known about the role of distal cues, such as environments and situations, in cue-reactivity. The aim of this study was to get an overview of contexts in which people smoke and to assess the relationship between contexts and smoking urges. Moderately addicted Belgian smokers (N = 110) recorded each smoked cigarette during four days and described the place and situation and the feeling they experienced when starting to smoke. The data demonstrate that different contexts were related to differences in the amount of craving and enjoyment that was experienced. Finally, differences in (amount of) contexts could be predicted by the level of nicotine dependence. These results are relevant for conceptualizing and optimizing smoking addiction treatments.

Conditioned craving cues elicit an automatic approach tendency.

In two experiments, we used a Pavlovian differential conditioning procedure to induce craving for chocolate. As a result of repeated pairing with chocolate intake, initially neutral cues came to elicit an automatic approach tendency in a speeded stimulus-response compatibility reaction time task. This automatic approach tendency, moreover, seemed to be sensitive to manipulations of extinction and renewal in the Pavlovian conditioning procedure. These findings corroborate and extend previous reports of automatic approach tendencies elicited by substance-relevant cues in addiction, while controlling for alternative accounts for such observations. Moreover, our data lend support to and extend learning models of cue-induced craving and addiction. Finally, we argue that the procedure we present here provides an ecologically valid behavioural tool that allows studying processes involved in cue-induced craving, addiction and relapse without relying on verbal report.

Return of experimentally induced chocolate craving after extinction in a different context: divergence between craving for and expecting to eat chocolate.

Unlike in fear conditioning, little attention has been devoted to extinction and renewal in appetitive conditioning, despite its relevance for extinction-based addiction treatments. We developed a paradigm, using a specific tray as a conditioned stimulus (CS) for eating chocolate (unconditioned stimulus, US), to investigate the effects of context change on acquisition and extinction of conditioned chocolate craving using an ABA renewal design. In Study 1 (n=32), participants successfully acquired chocolate craving, but unlike what is commonly observed in fear conditioning, craving did not extinguish. In Study 2, we separately assessed craving and US expectancy in a between-subjects design (n=64). US-expectancy data showed acquisition, extinction and renewal in the ABA group. The craving data did not follow this pattern, suggesting different mechanisms for craving and US expectancy. Similarities and differences between craving and US expectancy, as well as practical implications, are discussed.

Repeated cue exposure effects on subjective and physiological indices of chocolate craving.

The aim of this study is to investigate the effects of repeated unreinforced exposure to chocolate cues in persons reporting chocolate craving. Participants in the experimental group (n=40) received 10 consecutive brief exposures to chocolate cues in each of two sessions, separated by 1-3 days. Control participants (n=18) received two exposures at the start and end of each session. Chocolate craving was measured (alternately) through subjective report and the amount of saliva secretion to chocolate cues. Results showed a between-sessions decrease in both craving measures in the experimental group, whereas no differences in craving between sessions were observed in the control group. These results provide evidence for the effects of cue exposure treatment in chocolate craving.