Lynne Dawkins, Drugs & Addictive Behaviours Research Group, School of Psychology, University of East London
E-cigarettes are the subject of intense debate: some consider them one of the greatest public health breakthroughs of our time, with the potential to save millions of smoking-related deaths; others fear they could re-normalise smoking, undermining tobacco control efforts which have made smoking socially unacceptable.
E-cigarettes come in all sorts of shapes and sizes. Some, commonly referred to as first generation devices, resemble tobacco cigarettes (cigalikes) with an orange mouthpiece resembling a cigarette filter, a white battery and an LED which glows when the user inhales on the device. These devices comprise low-capacity disposable or re-chargeable batteries and combined cartridges and atomisers (cartomisers). Second generation devices resemble pens or gadgets and use larger batteries and fluid filled reservoirs (clearomisers or tanks), filled from bottles of e-liquid. Third generation devices bear little visual resemblance to cigarettes, use larger-capacity batteries, replacement heating coils and wicks for atomizers, and adjustable and programmable power delivery.
E-cigarette use (commonly referred to as ‘vaping’) resembles the act of smoking : the user holds the device and draws on it like a cigarette; the vapour produced is drawn into the lungs and exhaled like smoke; and tobacco (or menthol) flavouring mimics the taste of inhaled tobacco smoke. Moreover, first generation cigalikes look exactly like cigarettes and are often contained in boxes resembling cigarette packets. Although regular e-cigarette users (‘vapers’) tend to use second and third generation devices which deviate from a cigarette-like appearance (Dawkins et al., 2013), most e-cigarettes found in retail outlets across the UK and US (and therefore most likely to be encountered by smokers) are first generation cigalikes. This has led to a growing concern among public health officials that e-cigarette use may re-normalise smoking, especially if they look like cigarettes and their use is misperceived as smoking. Given the gradual cultural shift over the last 50 years which has transformed tobacco smoking from a ubiquitous socially acceptable behaviour into a distasteful or repugnant habit, fears abound that e-cigarettes may allow re-entry of tobacco smoking into public view.
So, just how important is cigarette-like appearance for a smoker transitioning to e-cigarette use? Or, is visual appearance irrelevant as long as there is effective nicotine delivery? If first generation cigalikes are indeed less effective than their refillable, newer generation counterparts and few smokers opt for them when presented with a refillable alternative, there would be little reason to encourage their promotion. Drawing on data from the combustible literature, although nicotine is clearly a critical component of tobacco smoking, increasing evidence points to the role of non-nicotine, sensorimotor factors – the look and feel of the cigarette. For example, smokers prefer smoking to other forms of nicotine administration (e.g. patch, gum, nasal spray) and report enjoying the hand-mouth activity, taste, smell and sensation of smoke in the respiratory tract (Parrott & Craig, 1995). Smokers have also been shown to prefer smoking a cigarette containing no nicotine (denicotinised) over receiving nicotine intraveneously (Rose et al., 2010) and denicotinised smoking can also reduce nicotine withdrawal symptoms and smoking urges (Barrett, 2010; Perkins et al., 2010).
In order to explore preferences for cigalikes versus later generation refillable devices, we asked 100 smokers who had little or no experience of e-cigarettes to choose between a first generation cigalike and a second generation eGo when both devices were placed in front of them. 50% chose the cigalike device and stated that they did so because it resembled a cigarette. Clearly, cigarette-like appearance is important for many smokers who are thinking about using an e-cigarette. But is cigarette-like appearance important when the e-cigarette is actually used? To address this question, we randomly assigned 63 abstinent smokers to one of two conditions: a first generation cigalike with a white battery and orange filter (white; cigarette similar condition) or a first generation cigalike with a red battery and orange filter (red; cigarette dissimilar condition). The flavour (tobacco) and nicotine content (18mg/ml) were the same in both conditions. Participants rated their urge to smoke and nicotine related withdrawal symptoms before, and 10 minutes after, using the e-cigarette. The reduction in urge to smoke and withdrawal symptoms was significantly greater for those in the white (cigarette-similar) condition compared with the red condition, especially for those who had not used an e-cigarette before (Dawkins et al., under review). We concluded that visual similarity to a cigarette is important for smokers who are new to e-cigarette use, at least after short term use in the lab. This could be an expectancy effect or a secondary reinforcing effect whereby cues (e.g. the visual appearance of the cigarette), by virtue of their continued association with nicotine delivery, become moderately pleasant in their own right, capable of alleviating some of the discomfort associated with not smoking.
Nevertheless, regular vapers tend to move away from cigalikes to second or third generation refillable devices (McQueen, Tower & Sumner, 2011) and there is some evidence that these may be more effective for quitting (Farsalinos et al., 2013), perhaps due to more efficient nicotine delivery (Farsalinos et al., 2014). We therefore explored whether a second generation eGo device was better than a disposable cigalike for reducing urge to smoke and nicotine withdrawal symptoms in 100 abstinent smokers who used the e-cigarette for 10 minutes. There was a significant reduction in craving and withdrawal symptoms in both groups. In other words, the disposable cigalike was as good as the second generation device, and both groups reported receiving a ‘hit’ from the e-cigarette. There were some differences though – those in the second generation condition rated the e-cigarette as more satisfying and were more likely to use it in a quit attempt (Dawkins et al., under review). Although there are hundreds of cigalike products available and these findings cannot be generalised to all first generation devices, they do demonstrate that cigalikes at least have the potential to be as effective as refillable devices for short term alleviation of tobacco craving and withdrawal symptoms. Perhaps as smokers transition from smoking to vaping however, cigarette-like appearance becomes less important alongside an identity shift away from a ‘smoker’.
Taken together, these findings suggest that first generation cigalike products may have their place among the plethora of e-cigarette devices, at least to draw smokers into initial e-cigarette use and away from smoking. Nevertheless, this needs to be balanced carefully against any disadvantage associated with a possible re-normalisation of smoking. Moreover, cigarette related visual cues, may even serve to maintain a tobacco smoking addiction if they remind the smoker of cigarettes, which may explain why second generation devices are preferred for stopping smoking. Nevertheless, until trials comparing cigalikes and refillables for quitting smoking are conducted, there is no compelling evidence as yet to stub out the cigalike.
Barrett SP. (2010). The effects of nicotine, denicotinized tobacco, and nicotine-containing tobacco on cigarette craving, withdrawal, and self-administration in male and female smokers. Behavioral Pharmacology, 21, 144-152.
Dawkins L, Kimber C, Puwanesarasa Y, Soar S. (under review). First versus Second Generation Electronic Cigarettes: Predictors of Choice and Effects on Urge to Smoke and Withdrawal Symptoms. Addiction.
Dawkins L, Munafò M, Christoforou, G, Olumegbon, N. (under review). The effects of e-cigarette visual appearance on urge to smoke and withdrawal symptoms in abstinent smokers. Nicotine and Tobacco Research.
Dawkins L, Turner J, Roberts A, Soar K. (2013). ‘Vaping’ profiles and preferences: An online survey of electronic cigarette users. Addiction 108, 1115-1125.
Farsalinos KE, Romagna G, Tsiapras D, Kyrzopoulos S, Voudris V. (2013). Evaluating nicotine levels selection and patterns of electronic cigarette use in a group of ‘vapers’ who had achieved complete substitution of smoking. Substance Abuse , 7, 139-146.
Farsalinos KE, Spyrou A, Tsimopoulou K, Stetopoulos C, Romagna G, Voudris V. (2014). Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices. Scientific Reports, 4, 4122.
McQueen A, Tower S, Sumner W. (2011). Interviews with ‘Vapers’: Implications for future research with electronic cigarettes. Nicotine and Tobacco Research, 13, 560-7.
Parrot AC, Craig D. (1995). Psychological functions served by nicotine chewing gum. Addictive Behaviors 20, 271-8.
Perkins KA, Karelitz JL, Conklin CA, Sayette MA, Giedgowd, GE. (2010). Acute negative affect relief from smoking depends on the affect situation and measure but not on nicotine. Biological Psychiatry, 67, 707-714.
Rose JE, Salley A, Behm FM, Bates JE, Westman EC. (2010). Reinforcing effects of nicotine and non-nicotine components of cigarette smoke. Psychopharmacology, 2010, 1-12.