3.2. Experiences and Use of Nicotine Products
As shown in Table 1
, more than half (55.2%) of participants indicated that they had used nicotine products previously. Nicotine patches were the nicotine product that most participants had previously used (55.2%).
There were three circumstances in which participants reported that they used, or had used nicotine products: to make a quit attempt; during periods of temporary or enforced abstinence; and as a form of harm reduction. Patches had often been used during in-patient hospital stays to reduce nicotine withdrawal symptoms when participants were unable to smoke.
“Actually, well, I did three days in detox and didn’t have a cigarette while I was in there and I used the patches and that was fuckin’ crazy. […] I was thinking about rolling it up and chewing it and start smoking it, so I couldn’t do that.”
A small number of participants described that they used nicotine products along with smoking to reduce their smoking, to act as a stop-gap measure if they didn’t have enough money to buy cigarettes or if they were unable to smoke for some other reason (e.g., while travelling).
“I find a lot of the time I’m buying the quit smoking products other [sic] than cigarettes merely because they might get me through a little bit longer than the smokes will, because I tend to smoke more if I have cigarettes. But in the same point, a lot of the time the price of the cigarettes and the price of the nicotine replacement products are very similar.”
One focus group participant, who was also an advocate for the use of vaping devices, reported having switched to a vaping device as a “harm reduction” measure.
“I started on the very small ones, which I think was probably the one that (name) was on, one that looked like a cigarette and they don’t actually give you enough bang for your buck. So for quitting smoking from a 16-a-day smoker, I have moved to … I think it’s like a third stage e-cigarette […] you’re still getting the deep feeling of the nicotine going in, you’re still getting the nicotine, so on a harm reduction it’s been fantastic.”
3.3. Views on Nicotine Products
A summary of participants’ views on currently available and prospective nicotine products are presented in Table 2
3.3.1. Vaping Devices
Vaping devices, including tank vaporisers and e-cigarettes, were the most popular nicotine products discussed, in terms of participants’ willingness to try (65.5% willingness in both cases). The focus groups also included a small number of keen advocates for these technologies. Consequently, the topic of vaping devices generated the most discussion.
Reported benefits of vaping devices included that they replicated the psychological and sensory experience of cigarette smoking (visible vapour, taste and smell). Vaping devices were also viewed as having fewer negative effects on others, such as the absence of the smell of smoke.
“It looks like smoke coming out and it doesn’t taste that bad. It’s sort of like you’re getting … because you can see the smoke and it is psychological in the brain.”
Personal preferences were evident in views on different kinds of vaping devices. While most participants liked the e-cigarette because it closely mimicked the positive elements of smoking cigarettes without its negatives, others indicated that e-cigarettes were an unattractive simulacrum and in some sense juvenile. For example, some compared them to a type of popular confectionary that resembled cigarettes that were once marketed to children.
“When you took a drag it would look like those lollies you bought that used to have the red stuff on them.”
There were related divergences in views on the tank vaporisers. Consistent with the idea that e-cigarettes were juvenile, some liked that the tank vaporisers looked different to cigarettes and were more clearly an adult product. Others took a contrasting view, identifying that the visual dissimilarity to cigarettes was a negative feature and a barrier to use, with some even pronouncing them to be “ridiculous” [FG4P1].
“The thing is they’re not trying to look like a cigarette. They are clearly something different. You can personalise them and they come in different colours. You can get some that are a bit quirky. They treat you like an adult with something you might want.”
Another respondent’s comment
“It doesn’t look like a cigarette should, would not make me want to smoke it.”
The relative size and weight of different vaping devices were also brought up as practical considerations. Those who liked e-cigarettes described them as “compact and […] seems easy to use” [FG4P9]. In contrast, tank vaporisers were viewed, negatively, as “bulky so it’s not going to fit in like your shirt pocket or your jeans or something.” [FG1P7]
One participant with experience of vaping devices, identified that they had transitioned from e-cigarettes to a tank vaporiser because the latter provided a more satisfying “hit”.
“I think just from experience I think you start off on the smaller one [e-cigarettes] because the ones that are like a cigarette, but as a smoker you’ll find they don’t quite give you enough and that is probably where you progress [to a nicotine vaporiser], it’s more like going for a larger tube. So it’s a bit of a culture around that. I think it’s about having more than one so people can go onto them.”
Given the lack of widespread availability in Australia of nicotine solution for refilling the devices, the need for organisational skills was raised as a necessary requirement for successfully switching from cigarettes to vaping devices. Some participants also reported concerns regarding the quality of nicotine liquids available.
“I think you would have to be organised and organise your finances and make sure that when it does run out you’ve got something to fill it up with, because that would be the time when you go, “Oh bugger I’ve run out of this” and you would go and buy a packet of cigarettes or whatever. Do you know what I mean?”
While generally positive regarding the prospect of vaping devices, some concerns were raised by participants about possible negative health effects as well as cost, environmental impacts and legal issues.
One participant reported that e-cigarettes had exacerbated their asthmatic symptoms.
“I found a problem with them and I tried them for a while and I get a bit of asthma and I found with the vapour it would make my lungs rattle a bit, so I would worry that long term you might get pleurisy or something from taking in the moisture, a bit of fluid on the lungs”.
Another participant did not like the idea of the environmental impacts associated with the disposable e-cigarettes, describing them as “pretty environmentally unsound” [FG3P4].
Some participants foreshadowed possible legal issues with the tank vaporiser, if it was mistaken for a “drug implement” by police [FG1P5] and it was recognised that these vaporisers could be used to consume cannabis oil.
Initial outlay and ongoing costs were a topic of discussion among participants and it was generally agreed that vaping would need to cost less than smoking to be an attractive option. Finally, vaping devices were not considered acceptable by those who expressed their desire to quit the “habit” of smoking and transition completely away from a lifestyle that included smoking.
“The cigarette thing I would not be interested in because all you’re doing is you’re still doing the same thing, basically […]. You’ve got to get away from that mindset of having to have something in your hand, you know.”
3.3.2. Nicotine Aerosol Inhaler
The Nicotine Aerosol Inhaler was the third most popular nicotine product discussed (58.6% willing to try). Like e-cigarettes, many viewed the nicotine aerosol inhaler favourably for the way that they mimicked the look of cigarettes and the behaviour of smoking.
“That would be alright and I could sit there with that in my hand I’d be alright. […] and it looks like a packet of cigarettes […] I like that you’re still holding the smoke.”
However, some participants were not interested in the aerosol inhaler for that very reason—describing that they wanted to give up the habit of smoking rather than simply substituting it with a similar behavior.
“Everybody else thinks it’s the smoking, I’m not really sure that […] Yeah but I’m not really sure that is why I smoke so having something like that really doesn’t attract me at all. […] [I want to get] rid of the habit.”
Once again cost was raised as a factor. Participants highlighted that products that were presented as alternatives to cigarette smoking needed to be cheaper in order to incentivise their use.
“I’d put it in the Quit thing or whatever. I don’t know, I think people would use it if it was financially viable. But if you’re having to give up things, [for] the same price as the cigarettes then the smoker is going to go for the cigarettes every time.”
The issue of generating product appeal was raised by one participant who highlighted the importance of making the product a desirable, rather than consoling, alternative to smoking. Comparison to a popular mid-strength beer (XXXX Gold) was given as an example.
“If it’s marketed as something cool party people want to use or that kind of thing I reckon it could work but that’s it. If it’s associated with losing something or giving something up then it’s got more nostalgia attached to it but if it’s seen as the new thing and everybody is doing this, have your XXXX Gold and your aerosol nicotine inhaler.”
3.3.3. Mouth Spray
Most participants were unfamiliar with the nicotine mouth spray but more than half expressed willingness to try it (55.2%). However, the one participant who discussed having tried the product described a negative experience in which they used too much, resulting in nausea. One participant expressed scepticism regarding the potential effectiveness of the mouth spray, due to its mode of delivery.
“I tend to think that because it’s just something that you spray in your mouth or whatever you don’t have the same effect of picking up a cigarette and putting it in your mouth like ordinary cigarette that might have a better chance of working.”
Taste was deemed an important factor in assessing the acceptability of this product by those who had not tried it before.
The participants with experience using nicotine lozenges seemed evenly split as to whether they thought lozenges had been effective or not. Just under one-half of participants (48.3%) expressed their willingness to try this product.
One participant commented positively regarding the similar kinetics of lozenges relative to smoking, albeit when used in tandem with another nicotine product:
“Yeah, I’ve tried the lozenges and I went for about five weeks without smoking in conjunction with an e-cigarette that didn’t have nicotine in it at that stage. I couldn’t find any that did, but I went for five weeks on the lozenges and that was quite good, and it was a bit of a distraction having them in your mouth too, you can sort of roll them around. […] so I still get the feeling of having a cigarette.”
Participants showed distinct preferences for lozenge type, including size and flavour, and had divergent opinions regarding their cost-effectiveness. One participant discussed feeling that nicotine lozenges were more addictive than cigarettes.
“I’ve tried the Nicabate [lozenges] which is now off the market. […] They’re off the market now and they were really good but they were very expensive and very addictive. I found that there was something, I was saying maybe there was something in them that Australia wouldn’t allow and so they took it off the market. It just, it would really give you a fix. [...] Yeah, and it was too full on because I needed them more than I needed a cigarette ... really badly. It was terrible.”
Other criticisms of lozenges included disliking their taste and finding them ineffective at alleviating cravings.
Participants had mixed views on the inhalator, with slightly more participants expressing negative views than positive ones within the context of the focus group. Fewer than one-half (44.8%) of participants indicated a willingness to try inhalators. Positive aspects of the inhalator that were identified included that it mimicked elements of smoking, although some participants considered inhalators to be less appealing than the vaporising devices because the inhalators did not produce a visible “smoke”.
“I don’t mind those, it gives me the drawing, […] It gives you that feeling of smoking, that sensation which is something to do with your hands side of things and if you are sitting around a bunch of smokers or you’re in a situation then you’ve got something that’s not quite, that’s similar to what having a cigarette might be tempted to be able to do instead of it, yeah.”
Another respondent’s comment
“No good […] because the vapour you see the smoke coming out and you’re drawing on something, the vapour is going to work.”
One person who had tried an inhalator commented that they appreciated that it had no discernible taste, while another who had a damaged throat described the product as “burn(ing) my throat” [FG4P4].
A considerable downside was the visual appearance of this product. Many described the product as looking like a tampon, with one participant commenting that they were embarrassed to be seen using it in public.
“You do feel crap using those. They are alright to use at home but they look so ridiculous when you’re outside.”
One participant’s account of inhalator use, highlighted a common theme in participants’ accounts of poly-nicotine product use. This participant described themselves as having “OD’d” [FG2P1] from using the inhalator in conjunction with a patch. Participants frequently reported combining the use of different nicotine products, as well as using nicotine products while continuing to smoke cigarettes. Some described experiencing nausea while using multiple products, possibly due to over-use.
Dissolvable oral strips were mostly unknown to participants and tied with the inhalator in terms of acceptability (44.8% willing to try this product). The two participants who reported having tried dissolvable strips did not consider them to be effective, with one participant stating that they did not find the strips “strong enough” [FG2P1].
Snus, patches and gum were tied in last place in terms of participants’ willingness to try and fewer than half (41.4%) expressed a willingness to try these products. Focus group participants were mostly unfamiliar with Snus, a smokeless tobacco that is not available for sale in Australia. Consequently, participants expressed uncertainty and mixed interest, with some proclaiming that “it looks weird” [FG3P1].
In the context of discussing an unfamiliar product, many participants identified the need to be able to “try it first to find out if it’s for them” [FG2P2]. Participants highlighted that different options, including snus, might work for different people, depending on their preferences.
“Might take off, I don’t know about other smokers, but for a person that likes the draw, no, but for other people, yes, because other people like the chewing gum or it works for them, so it possibly could.”
Some also pointed out that trialling of nicotine products needed to be subsidised as they could not afford to try multiple products in order to find the best option for them.
Snus was recognised as having fewer health harms than cigarette smoking as well as having the advantage of being able to be consumed in areas where smoking was banned. Barriers to using snus included its being an unsuitable option for those with oral prostheses.
“You can use it on the bus, health concerns. You’re not dragging tar into your lungs.”
As noted already, although one of the least favoured, patches were the most commonly experienced nicotine product discussed. Many participants had used nicotine patches during periods of hospitalisation in a smoke-free facility.
“When I was there it lasted the whole five days and I didn’t have a craving whatsoever.”
While some positive experiences were mentioned, most of the discussion centred on negative experiences with the product, particularly side effects such as nightmares and allergic reactions.
“If you ask me the patches all they do is give you nightmares, if you put them on while you are asleep you get nightmares.”
Another respondent’s comment
“I think I must have been allergic to the adhesive because I would pull the damn thing off and there would be these really itchy red, angry red you know like a rash.”
Some participants also found them ineffective, particularly insofar as they didn’t replace the behavioural aspects of smoking.
“The patches don’t do anything because they aren’t addressing that to do with your hand and the psychological…”
Views on chewing gum were mixed, although mostly negative experiences were reported. One participant reported that they were currently using gum and that it was working for them [FG2P2]. However, others described it as unpalatable and difficult to use as directed.
“The chewing gum is useless. […] I’ve tried once the gum and like you said it’s like licking an ashtray. It is absolutely putrid.”
Another respondent’s comment
“You are supposed to chew it and then park it. But I didn’t know that when I’d done it too so it was 15 s it was like hard. […] No, disgusting. I wouldn’t recommend it to somebody.”
Similarly to the Snus, participants with oral or dental prostheses reported that they could not use the gum.
3.4. Views on the Use of Nicotine Products as a Long Term Substitution for Smoking
Participants wavered in their views on the idea of using nicotine products as a long term substitute for smoking. When asked directly about their interest in long-term substitution of smoking with nicotine products, participants generally responded in the affirmative, that they would be interested in substituting smoking for a less harmful alternative. However, their deliberations on this topic indicated a more complex narrative and several impediments to activating this disposition were identified (Table 3
3.4.1. Swapping One Addiction for Another
Some participants were wary of the idea of trying to substitute smoking for another “habit” because they did not differentiate between different kinds of habit, which they viewed globally to be an undesirable compensating mechanism.
“It would be like swapping smoking to take up gambling or something. It’s about, it’s about… being able to condition yourself into not requiring anything as a crutch.”
Another respondent’s comment
“[…] long term habit? No. […] You may as well just keep smoking if it’s just going to be another habit”.
This discourse aligned with moral conceptualisations of addiction and in some cases participants indicated that the habitual behaviour of smoking was more concerning than the health harms it caused. However, the concern with addiction itself also resonated with participants’ recounting of how their use of different addictive substances was linked. This included highlighting that cutting down or quitting smoking could promote an increased use of other (harmful) substances and vice versa.
“I haven’t had a drink for three months now it has been for me, but I find I’m using these cigarettes to substitute the alcohol more.”
3.4.2. What It Means to Quit
Another reason for not liking the idea of switching to a long term nicotine substitute was that it was inconsistent with their pre-existing conceptualisation of stopping smoking, which involved an idealisation of radical change or transformation in their lifestyle. Those who viewed the idea of quitting smoking as transformational valorised the idea of becoming a non-smoker. Continuing to use nicotine in another form conflicted with this ideal.
“If you’re going to quit smoking then you’re quitting a lifestyle [later in the interview] I think what would work for me [to quit] is going to a day spa for two days and getting completely cleansed internally and externally and then coming out like a butterfly.”
In a similar vein, several participants highlighted how diet, and eating healthily, was an important aspect of quitting smoking.
3.4.3. Health Risks
Overall, participants expressed mixed views regarding the extent to which product health risks would influence their smoking behaviour with regard to switching or quitting. A number of participants pointed out that they continued to smoke in spite of knowing the health risks associated with it.
“I love a cigarette. If I can’t have one in the morning when I wake up then I just go back to bed. I’m starting to feel like that often now too, so … but yeah. No I would be happy to die of lung cancer.”
Some acknowledged that observing other smokers with tobacco related disease might be insufficient reason for them to quit but that they would quit if, and when, they discovered they were ill.
“I recently just found out a very close friend of mine […] got lung cancer and […] tumours on the brain. […] it hasn’t stopped me smoking, but every time I have a smoke I think about it. […] to be honest I don’t want to quit at the moment, and I think it will probably take something like where you’ve got cancer for you to quit.”
One participant believed that the chemicals in cigarettes, in addition to nicotine, were part of what made them enjoyable, suggesting that a clean nicotine product would be unable to provide an adequate replacement.
“Because it’s phosphorous, like 43 different chemicals to make it taste better.”
There was some indication that at least some smokers were applying a higher standard to their deliberations over the health risks of alternatives to cigarette smoking than to cigarette smoking itself, demanding that any alternative must be completely risk free to consider using it.
“If it had no health risks to it, yes. […] I wouldn’t be interested if it was a pill and if it was going to affect my heart, my liver, my kidneys then I wouldn’t be interested at all.”
The need for an alternative to smoking to be viewed as an attractive consumer item was identified by some smokers. Along with a prominent (although not universally shared) interest in using alternatives to cigarette smoking that shared its aesthetic and sensory elements without its negatives (e.g., smell), one participant identified that associating nicotine products with the loss of something made it a less appealing option than if it was positively marketed as a desirable lifestyle accoutrement.
“I think that not every nicotine product needs to be marketed as a quit aid. I think some nicotine products can be marketed as part of a lifestyle …”
Several financial angles were discussed with respect to the idea of substituting smoking for other nicotine products. Firstly, was the cost of smoking relative to the cost of nicotine products. The (increasing) cost of smoking was an important driver to quit. Relatedly, however, the idea of substituting smoking for an alternative that could prove just as costly, made this switch unappealing.
“When you say “long term” the objective is to give up isn’t it? You wouldn’t want to be smoking them [inhalator] for the rest of your life would you? […] I’m thinking of the expense which is the big drawback for smoking.”
As discussed earlier in reference to specific nicotine products, the second cost issue that was discussed related to the perceived need to incentivise smokers for the presumed inevitable trade-offs involved with changing from cigarettes to other nicotine products. Unless the alternative was just as satisfying as smoking, participants recognised that it would be hard to maintain the alternative habit. Accordingly, there was a strong belief that there should be government subsidies for less harmful nicotine products. In the same manner as deliberations over health risks, it appeared that the cost-effectiveness of alternatives to smoking were judged according to a higher standard than that of cigarettes.
The final cost issue that participants raised pertained to the opportunity cost of trialling different types of products in order to find the one that was most acceptable. Participants’ preferences varied between individuals and consequently the number of products a smoker may need to trial in order to find one that worked represented a high potential cost.
“Well we don’t earn a $1,000 a week so we can’t afford to get something unless you’re absolutely 100% it works. We haven’t got time for gimmicks. […] I can’t even go to McDonalds to buy take-away, let alone buy something that is $38.”