Kiev UCC C. Russell

How Smokers Become Vapers,
and How Doctors Can Help
Christopher Russell Ph.D.
Centre for Substance Use Research,
Glasgow, United Kingdom
russell@csures.org
2016 Ukrainian National Congress of Cardiologists
Kiev, Ukraine
23 rd September 2016

The Case for Tobacco Harm Reduction
• Using data from the World Health Organisation’s
(WHO) GlobalInfo Database, it is estimated that, if
all the multipronged tobacco control programs in the
world were implemented fully and immediately in
2010 through to 2030, the global prevalence of
smoking would reduce from 794 million smokers to
523 million smokers (Mendez, Alshanqeety and
Warner, 2012).

The Case for Tobacco Harm Reduction
• What is to be done with the 523 million smokers who are
not deterred by tobacco control measures and do not
respond to professional assistance and peer
encouragement to quit?
• An intuitive, pragmatic approach would be to encourage
and assist those who are not interested, willing or able to
quit smoking to use nicotine products that are
substantially less toxic than inhaled tobacco smoke.
• These alternative products should replicate many of the
reasons for, but not the effects of cigarette smoking.

Understanding Drug Motivation
• Innovation of and persuasion to use
alternatives requires we understand and
acknowledge, without judgment, why people
continue to use harmful drugs and why they
often fail to stop using drugs despite a stated
desire and intent to do so.

Operant Learning Theories
• Drug use is motivated by the consequences that
follow drug use.
• More likely to repeat use of a drug if previous use
yielded:
1. Positive reinforcing effects – e.g. enhancement
of pleasurable feelings, confidence, euphoria.
2. Negative reinforcing effects – e.g. reduction of
negative affect, stress, sad mood, tension.
• “Addicted drug users sustain their drug use
largely to manage their misery” (Baker et al.,
2004: 34).

Drugs Are Pleasurable but
Drug Treatment is Miserable
• Drug use is often reinforced in spite of harmful
consequences by the drug’s pleasure-enhancing and
affect-reducing effects on the brain and body.
• Yet assisted cessation (treatment), unassisted
cessation (‘cold turkey’) and longer-term recovery
from drug misuse are typically miserable, painful
processes, a time devoid of pleasure.

Drugs Are Pleasurable but
Treatment is Miserable
• Consequently, many people who express a
desire to stop using a drug quickly rationalize a
resumption of drug use in order to reexperience
pleasures that were not replaced
during their treatment or recovery.

Less Pleasure, More Relapse
• The absence of pleasure from the products and
methods we approve for deterring harmful
drug use is often what causes these methods to
fail to deter individuals’ resumption of
pleasurable but harmful drug use.
• Better rationalise change by offering people
alternatives to harmful substances/behaviours
that yield as much or more pleasure than the
harmful substance.

Tobacco Harm Reduction
• Smokers encouraged and supported to use a variety of
low-risk nicotine products in place of regular cigarettes:
• Nicotine patch
• Nicotine gum
• Nicotine lozenge
• Nicotine mouth spray/ ‘mist’
Smoking cessation medications
• Varenicline (Champix)
• Bupropion (Wellbutrin)

The Phenomenon of E-Cigarettes
However…
• Without mass marketing
• Without public health promotion
• Without doctors’ endorsement
Ø Millions of people have switched from smoking
cigarettes to vaping e-cigarettes.
• In 2015, there were an estimated 2.2 million people in
Great Britain using an e-cigarette, of whom
approximately 836,000 (38%) had switched completely
away from smoking to vaping (Office for National
Statistics, 2016).

The Potential of E-Cigarettes to
Reduce TRH
GOOD NEWS
• In 2015, 2.2 million people in Great Britain
using an e-cigarette…
• Of whom, approximately 836,000 (38%) had
switched completely away from smoking to
vaping (Office for National Statistics, 2016).

Why?

Why?
• Simple: E-cigarettes are sold as pleasure
substitutes, not therapeutic products.
• Pleasure of a reduced risk alternative product
is rooted in whether the product is
conceptualised as:
A. Medicinal, indicated for a medical condition.
B. Intended for functional recreational use,
consumed by choice as a means to change a
behaviour.

Not a Therapeutic Product
• Therapeutic products are implicitly marketed
as a ‘cure’ or ‘remedy’ to disease of addiction,
to behaviours compelled by the pharmacologic
actions of nicotine on the brain and body.
• Therapeutic products are not intended to be
pleasurable to use – they are intended to be
tolerable.

A Consumer Product
• Difference = E-cigarettes are sold to people
who view smoking as a choice, something that
is done for reasons.
• E-cigarettes are conceptualised by vendors and
users as a pleasurable alternative choice to
smoking.

Before E-Cigarettes
Before e-cigarettes, quitting smoking was miserable:
• Smoking viewed as a disease requiring medical
intervention, i.e. with medicines and counselling by
medical practitioners in medical settings.
• Goal of treatment = avoid pain, stabilise, avoid sinking
lower.
• Products = not intended to enhance pleasure; process
not about pursuing acute pleasurable states.
• Products = ineffective for most and not enjoyable to
use. Medicines intended to be therapeutic, not
pleasurable.

Before E-Cigarettes
Before e-cigarettes, quitting smoking was miserable:
• Setting = compared to shopping malls, sports venues,
restaurants, pubs, clubs, casinos and any other place
that consumers look forward to being in, clinics and
smoking cessation services are miserable, depressing
places.
• No person who attends really wants to be there or looks
forward to going there. The thought of merely showing
up is a grind.
• Make appointment, be on time.
• Given limited time.

Before E-Cigarettes
Before e-cigarettes, quitting smoking was miserable:
• Viewed/treated/talked to like you are a patient with a
disease.
• No one goes to the doctor when they’re well….if go,
must be sick, ill, or about to be.
• Talk to someone who likely hasn’t been through the
process they’re guiding you through (most doctors are
lifetime non-smokers) and do not appreciate first-hand
the role of pleasure in maintaining smoking, and so the
importance of retaining pleasure in alternative
behaviours.

With E-Cigarettes
With e-cigarettes, quitting smoking is enjoyable:
• Smokers are not patients and e-cigarettes are not drugs.
• Smokers are consumers who can be persuaded to use
alternative consumer products to tobacco.
• You are not sick; you don’t need treatment.
• E-cigarettes aren’t a form of treatment for a condition; they
are a pleasurable, low risk alternative to a pleasurable high
risk product.
• People helping themselves and their friends: selfdetermination
and community.
• Don’t need a prescription or a doctor’s say-so.

With E-Cigarettes
With e-cigarettes, quitting smoking is enjoyable:
• Setting (vape shop) is vibrant, air of positivity, understanding,
support, willingness to share experiences and give advice. No
judgement about past failed attempts to stop smoking.
• Setting is bright colours, fun music, casual dressed assistants
offering help,
• Open 9-6, no appointment necessary, come as often or as little as
you want,
• Try before you buy
• Talk to customers as well as sellers,
• Variety of choice is vast, the combinations seemingly endless, the
innovation is perpetual, always a new device and flavour to be
discovered.

With E-Cigarettes
With e-cigarettes, quitting smoking is enjoyable:
• Cessation from nicotine use is not the long-term
goal, nor is there pressure for this to be your goal.
• Now we have something that makes quitting
smoking fun!
• Who would have thought even 10 years ago that
smokers would have easy access to products that
are less expensive than smoking, less harmful
than smoking, and more enjoyable than smoking?

Pleasure/ Enjoyment Is…
• Taste, flavours.
• But the pleasures of using e-cigarettes are so
much more than the flavours…

Pleasure/ Enjoyment Is…
• Confidence – pleasure is knowing you are
capable of change, that you are in control.
• Community – pleasure is meeting new people
through vaping and discovering new interests.
• Hobby – technology, clouds, models, building
coils, mixing flavours.
• Self-determination – pleasure is taking health
into one’s own hands.
• Growing old in good health – pleasure is living
healthier for longer, becoming a grandparent,
seeing your children grow up.

Pleasure Drives Harm Reduction
• E-cigarettes have quickly and decisively become
the product of choice among people who want to
quit smoking primarily because they replicate and
extend the pleasures available through smoking,
to levels unmatched by any other nicotine
alternative to tobacco cigarettes.
• By providing pleasure and a plethora of reasons to
continue use, tobacco harm reduction will be
achieved to a level not achieved by any other
alternative nicotine product or smoking cessation
medication.

Regulate Harm, Not Pleasure
• To what extent should health policy regulate an
individual’s pleasure experienced as part of the
process of healthy behavior change?
• Pleasurable experiences DRIVE all behaviour,
including healthy behaviour change.
• To regulate is to moderate.
• To moderate pleasure of using reduced-risk
alternatives to harmful substances is to increase
the risk of people resuming use of high-risk,
pleasure-enhancing substances.

Recommendation
• Innovate products and substances that replicate
the reasons for use, but not the effects of use of
harmful substances.
• In most cases, an enhancement of pleasure and/or
a reduction of stress are a person’s reasons for
harmful drug use
• Pleasure and stress reduction must therefore be
functions of any product or substance we offer to
people as a viable, competitive alternative to use
of harmful drugs.

The Potential of E-Cigarettes to
Reduce TRH
GOOD NEWS
• In 2015, 2.2 million people in Great Britain
using an e-cigarette…
• Of whom, approximately 836,000 (38%) had
switched completely away from smoking to
vaping (Office for National Statistics, 2016).

The Potential of E-Cigarettes to
Reduce TRH
BAD NEWS
• 36% (3.17 million) of the approximately 8.8
million smokers in Great Britain have never
tried using an e-cigarette.
• Additionally, seven in every ten GB smokers
who trial an e-cigarette – 41% (3.61 million) of
all smokers – do not go on to become a regular
e-cigarette user.

‘Pushing the Switch’
• Persuading more smokers to try an e-cigarette,
and then supporting them to persist with an e-
cigarette as an alternative to smoking, is vital to
the success of e-cigarettes in reducing tobaccorelated
harm.
Q. How can more smokers be persuaded to try using
an e-cigarette in place of regular cigarettes, and then
switch completely from smoking to vaping?

10 Ways Doctors Can Inform
Smokers About E-Cigarettes
1. What is an electronic cigarette?
2. How does an electronic cigarette work?
3. Who are electronic cigarettes for?
4. Who are electronic cigarettes not for?
5. What is the available evidence to date on the health risks of
using e-cigarettes?
6. Does nicotine cause cancer?
7. What about nicotine addiction?
8. Should bystanders be worried about second-hand exposure to e-
cigarette vapour?
9. Why do smokers first decide to try using e-cigarettes?
10. Why do smokers completely switch to vaping?

What is an electronic cigarette?
• Electronic cigarettes – or ‘e-cigarettes’ – are
battery-powered handheld devices that deliver
nicotine to the user in a vapour rather than in
smoke.

How does an electronic cigarette work?
• E-cigarettes use battery power to heat a solution
containing water, nicotine propylene glycol and/or
vegetable glycerine, and typically also some
flavouring.
• When the user sucks on the e-cigarette’s
mouthpiece, a sensor detects air flow that
activates a heating element, which heats the
solution so that it evaporates.
• Heating this solution creates a vapour that
delivers the nicotine, and the user inhales this
vapour.

Who are electronic cigarettes for?
• They are for smokers who want to quit using
tobacco.
• They are for smokers who have tried other
methods of quitting without success.
• They are for ex-smokers who do not feel
confident in their ability to avoid resuming
smoking without using a nicotine product.

Who are electronic cigarettes not for?
• They are not for smokers who want to continue
using tobacco.
• They are not for ex-smokers who are confident
in their ability to avoid resuming smoking
without using a nicotine product.
• They are not for non-smokers.

What is the available evidence to date on the
health risks of using e-cigarettes?
• E-cigarettes do not contain tobacco, do not combust any material,
and so do not create smoke.
• The aerosol, or vapour, produced by e-cigarettes significantly
reduces the production of harm or potentially harmful chemicals.
• The vapour produced by e-cigarettes can contain some of the
toxicants present in tobacco smoke, but at levels that are much
lower, and below levels that are known to cause harm to humans.
• In normal conditions of use, toxin levels in inhaled e-cigarette
vapour are probably well below prescribed threshold limit values for
occupational exposure, in which case significant long-term harm is
unlikely.
• Scientific studies have shown that switching from cigarettes to e-
cigarettes significantly reduces your body’s exposure to harmful or
potentially harmful chemicals.

What is the available evidence to date on the
health risks of using e-cigarettes?
• While using an e-cigarette may not be 100% safe, most of the
chemicals that cause smoking-related diseases are absent from e-
cigarette vapour, and the chemicals that are present are found at
levels that pose little harm to health.
• The long-term health effects of e-cigarette use are unknown but,
compared with cigarettes, e-cigarettes are likely to be much less, if
at all, harmful to users or bystanders.
• Evidence suggests the possibility that some harm from long-term e-
cigarette use cannot be ruled out.
• Sustained exposure to low levels of toxins in e-cigarette vapour over
many years may pose some risks to health, particularly in relation
COPD and lung cancer. But the magnitude of these risks is likely to
be very small in absolute terms, and substantially smaller than the
risks arising from sustained tobacco smoking.

What is the available evidence to date on the
health risks of using e-cigarettes?
• Public Health England states that e-cigarettes are likely to be at least
95% less harmful to your health than smoking normal cigarettes.
• The Royal College of Physicians states the hazard to health arising
from long-term vapour inhalation from the e-cigarettes available
today is unlikely to exceed 5% of the harm from smoking tobacco.
• E-cigarettes are likely, in the near future, to pose the same risks as
licensed nicotine replacement therapies, such as the nicotine patch
and nicotine chewing gum.
• E-cigarette use releases negligible levels of nicotine into the air with
no identified health risks to bystanders.
• As smoking cessation is associated with a reduction in respiratory
symptoms in people with respiratory disease, many smokers who
switch to an e-cigarette are likely to experience improvements in
respiratory symptoms.

Does nicotine cause cancer?
• There is no evidence that nicotine is carcinogenic.
• There is little doubt that smoking causes cancer,
however nicotine is not the culprit.
• It is the products of combustion which cause
cancer in smokers and these are either absent in e-
cigarette aerosol, or present in amounts below
levels which are known to cause harm to humans.
• The nicotine in e-cigarette solutions (‘e-liquids’)
is the same nicotine that is used in nicotine
replacement products, such as patches and gums,
which are which are widely used and prescribed.

What about nicotine addiction?
• Using nicotine is no worse than drinking coffee,
say many experts.
• Nicotine itself is not a particularly hazardous
drug. The nicotine in e-cigarettes poses no more
danger of a harmful addiction than drinking a few
coffees on a daily basis, and no-one would seek to
ban, or limit, adults' enjoyment of their coffee.
• Most long-term e-cigarette users who no longer
smoke rate their dependence on e-cigarettes as
‘low’.

100
E-Cigarette Dependence Self-Rated
by 16,264 U.S. Former-Smoking Vapers
90
PROPORTION OF PARTICIPANTS (%)
80
70
60
50
40
30
20
10
12.5
49.9
28.7
9
None
Low
Medium
High
0
E-CIGARETTE DEPENDENCE CATEGORY

Should bystanders be worried about secondhand
exposure to e-cigarette vapour?
• Bystanders are very unlikely to be harmed by
people using their e-cigarettes in public spaces,
indoors or outdoors.
• E-cigarettes do not emit smoke, and there are no
known harms to bystanders from second hand
vapour.
• There is therefore no scientific basis on which to
ban vaping in public places – but be considerate
of other people who may be annoyed by the sight
or smell of vapour.

Why do smokers first decide to try
using e-cigarettes?
1. E-cigarettes are being used almost exclusively as safer alternatives to
smoked tobacco, by confirmed smokers who are trying to reduce harm to
themselves or others from smoking, or to quit smoking completely.
2. Currently experiencing smoking-related health problems.
3. Cigarettes cost too much.
4. Curiosity
5. Belief that e-cigarettes are a safer alternative to tobacco cigarettes.
6. Tried other smoking cessation products/methods but nothing has worked.
7. Recommended by an e-cigarette user.
8. Experiencing respiratory problems.
9. Hate the smell of smoke on clothes, fabrics etc.
10. Convenience of using indoors, smoke-free places.
11. Watched others die from a smoking-related disease.

To quit smoking
49%
Experiencing unspecified smoking-related health problems
33%
Cigarettes cost too much/ to save money
21%
Curiosity/ novelty/ just to try it
Believe e-cigarettes are a safer alternative to tobacco
Tried other products/methods but nothing worked
11%
11%
11%
Reason Given for First Trying an E-Cigarette
Someone recommended to me/ observed someone using one
Experiencing respiratory problems
Hate the smell of tobacco smoke
Convenience/to use in non-smoking areas
Get nicotine without harms of smoking
Quit to please someone
To cut down smoking
Attracted to e-cigarette flavours
Replicate smoking behaviours/sensations with safer product
Received medical diagnosis of ill health
To avoid producing second-hand smoke
Saw advertising, became curious
Hate the smell of smoke on clothes, fabrics
Feel stigmatised as a smoker
Poor dental health caused by smoking
Had seen others die from smoking-related disease
Pressure from someone to quit smoking
Feeling gross/disgusting from smoking
Poor physical appearance attributed to smoking
To avoid being around smokers
8%
8%
8%
6%
5%
5%
3%
3%
3%
3%
2%
2%
1%
1%
1%
1%
1%
1%
0%
0%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Percentage of Participants Citing Reason
Figure 2. Proportion of former-smoking vapers (n = 3,904) citing reasons for first trying an e-cigarette.

Why do smokers completely switch
to vaping?
1. Enjoyment, pleasure
2. ‘Keeps me from going back to smoking’ (i.e. relapse
prevention)
3. ‘Health has improved since I started vaping and quit
smoking’
4. ‘ I enjoy the flavours’
5. Feels like a safer alternative to smoking.
6. Vaping is less expensive than smoking.
7. Vaping satisfies nicotine cravings as much as
smoking.
8. No smell/good smell from vapour.

Advice from Former-Smoking
Vapers to Current Smokers
1. Pass on vapers’ advice to smokers.
2. Encourage smokers to talk to vapers, ask
questions.
3. Introduce smokers to vapers.

‘I know what you’re going through,
I’ve been there; I’m happy to help’

‘I know what you’re going through,
I’ve been there; I’m happy to help’
‘Be patient; don’t expect miracles; take
small, meaningful steps consistently’

‘I know what you’re going through,
I’ve been there; I’m happy to help’
‘Be patient; don’t expect miracles; take
small, meaningful steps consistently’
‘If you smoke, don’t beat yourself up, it
happens! Pick yourself up and go again!’

‘Don’t compare yourself to anyone
else, just do what you can do; Don’t
measure how far you have to go,
measure how far you have come.’

‘Don’t compare yourself to anyone
else, just do what you can do; Don’t
measure how far you have to go,
measure how far you have come.’
‘Always be mindful of the harms you
are avoiding by vaping
and not smoking.’

Thank You For Listening
It has been a pleasure!
Questions?
For slides…
Dr Christopher Russell
russell@csures.org