Are e-cigarettes more addictive than tobacco?

All of us are familiar with the scene: a bunch of teenagers absentmindedly puffing away at mango-flavoured vapers. But are these trendy and colourful gadgets actually more addictive than old-school cancer sticks?

Vaping has exploded in popularity, with over 3 million adult vapers currently in the UK alone (Action on Smoking and Health, 2022). E-cigarettes remain controversial, many people use them as a cessation aid while scientists worry about their role in increasing the risk of smoking among youth. We know that e-cigarettes do not include many harmful chemicals that cigarettes include (Collier, 2017), yet the long-term impacts of e-cigarettes are unknown (Marquez et al., 2021). In the USA, no e-cigarette product has been approved by FDA as a smoking cessation device. Similarly, in the UK, e‑cigarettes are not licensed as medicines but are regulated by the Tobacco and Related Products Regulations (2016). The National Institute for Health and Care Excellence (NICE) recommends providing e-cigarettes as an option for smokers who would like to stop smoking. Nevertheless, more research is needed to determine the safety and effectiveness of e-cigarettes as a smoking cessation aid.

An important issue is whether e-cigarettes cause addiction just like deadly tobacco. Previous research suggests that the risk of addiction, which is typically measured by craving or immediate e-cigarette use after waking, is lower in e-cigarette users compared to smokers (Liu et al., 2017; Strong et al., 2017). However, there are lots of unknowns regarding the relationship between e-cigarettes and dependence. In this new cross-sectional study, Lohner and colleagues analysed the results of a survey of 832 adults who use e-cigarettes in England to understand perceptions of e-cigarette addiction. Their study explores to what extent e-cigarette users experience dependence, and how this compares to tobacco.

Little research has been conducted to determine the safety and effectiveness of e-cigarettes to aid smoking cessation.

Methods

The researchers conducted a UK-based cross-sectional study. In total, 832 e-cigarette users in England participated in the survey and self-reported their perceived addiction to e-cigarettes and perceived addictiveness in comparison to tobacco cigarettes. The study explored the connections between perceived addiction and signs of addiction, including the time it takes to vape for the first time in the morning, the urge to vape, and nicotine strength, as well as vaping characteristics such as frequency and enjoyment. The authors adjusted their analysis for sociodemographic characteristics, such as age, gender, education and tobacco cigarette smoking status, and conducted sensitivity analyses to control for confounding factors and bias.

Results

Of all participants, 17% reported feeling very addicted to e-cigarettes, while 35% considered e-cigarettes equally addictive as tobacco cigarettes, and just below 6% felt e-cigarettes were more addictive than tobacco cigarettes. Participants were predominantly young in age (28% were 18-24; 27% were 25-39), male (64%), and moderately educated.

The study showed that several factors linked to nicotine addiction also related to feeling very addicted to e-cigarettes. These included vaping right after waking up, getting strong urges to vape, and using high-nicotine e-liquid. Study participants who vaped within 5 minutes of waking were more likely to report feeling very addicted compared to those who waited over an hour before vaping. Similarly, those reporting strong urges to vape had higher odds of feeling very addicted relative to moderate urges. Additionally, liquid nicotine levels had a role in addiction too as people using very high-nicotine e-liquid (>15mg/ml) had higher odds of feeling very addicted compared to those using low or no nicotine. In terms of vaping patterns, using e-cigarettes every day, and getting extreme enjoyment from vaping were also found to be associated with feeling very addicted.

When looking at perceived addictiveness relative to smoking tobacco, the use of e-cigarettes within 5 minutes of waking and daily vaping were associated with a higher likelihood of viewing e-cigarettes as equally or more addictive compared to cigarettes. But most signs of addiction weren’t really tied to thinking e-cigarettes are more addictive than smoking. The only exceptions were vaping right after waking up and vaping daily, which related somewhat to perceiving e-cigarettes as very addictive.

Overall, this study found that e-cigarettes seem to have some addictive potential, but most users don’t consider them as addictive as tobacco cigarettes. Most e-cigarette users in this study considered themselves not addicted or only somewhat addicted to e-cigarettes and more than half considered e-cigarettes to be less addictive than tobacco cigarettes.

Markers of nicotine addiction were associated with feeling highly addicted to vaping, but most users considered e-cigarettes less addictive than tobacco.

Conclusions

The study shows that while some e-cigarette users show signs of dependence, the overall prevalence of perceived addiction and markers of addiction is lower. It appears that e-cigarettes can be addictive, although perhaps not to the same extent as tobacco cigarettes. However, there is still a risk of dependence for some users. It may be useful to keep track of nicotine consumption in order to spot those who are developing an addiction. The study also shows that markers of addiction to e-cigarettes and the perceived addiction were consistent.

The causal link between e-cigarettes and addiction is muddied by previous or current tobacco addiction.

Strengths and limitations

This study has a relatively large sample size and uses validated methods. However, it has a cross-sectional design, and cannot establish a cause-and-effect relationship or analyse behaviour over a period of time. Perhaps a more important limitation is that all the participants were current or former cigarette smokers, and only 165 used e-cigarettes exclusively. Hence, it is not possible to establish whether e-cigarette use created addictiveness that was not already there because of cigarette smoking. Similar to many other studies in this area, the study relies on self-reporting, and there is a risk of misreporting. Apart from these, the participants were all adults and the addictiveness of e-cigarettes amongst young people and children might be very different as previous evidence suggests that young people who vape might be more likely to become smokers compared to those who don’t consume e-cigarettes (Barrington-Trimmis, 2016).

The addictiveness and safety of e-cigarettes need to be further explored with longitudinal studies.

Implications for practice

This study provides further evidence for providing e-cigarettes as a cessation aid for adult smokers as many users perceive e-cigarettes as less addictive than smoking. Since tobacco smoking is more harmful than e-cigarettes, the small risk of developing dependence for a subset of e-cigarette users found in this study seems negligible. Monitoring markers of dependence like time to first use, nicotine levels, and enjoyment may help identify problematic use.

Therefore, clinicians should monitor and assess patterns of e-cigarette use and nicotine addiction in patients, especially in individuals showing signs of heavy e-cigarette use, strong urges to vape, and early morning vaping. These factors can signal a high level of addiction and the need for support. Additionally, the study shows that an important number of e-cigarette users (just below 6%) perceive e-cigarettes as equally or more addictive than tobacco cigarettes. This perception may influence their attitudes toward quitting or switching from smoking to vaping. Thus, discussing the perceived addictiveness of e-cigarettes with cigarette smokers might be important in defining the right cessation support for individuals.

More research is required to thoroughly understand the factors contributing to e-cigarette addiction. This may involve investigating the role of different e-liquid nicotine levels, patterns of use, and psychological factors as well as comparing addiction in people who have only used e-cigarettes to tobacco smokers who have never used e-cigarettes in longitudinal studies.

Clinicians can monitor nicotine levels and dependence on e-cigarettes and help to prevent misuse.

Statement of interests

The author does not have any conflict of interest. The views expressed in this blog belong to the author and not NICE.

Links

Primary paper

Lohner, V., McNeill, A., Schneider, S., Vollstädt‐Klein, S., Andreas, M., Szafran, D., Grundinger, N., Demjén, T., Fernandez, E., Przewozniak, K., Tountas, Y., Trofor, A., Zatonski, W., Willemsen, M. C., Vardavas, C., Fong, G. T., & Mons, U. (2023). Understanding perceived addiction to and addictiveness of electronic cigarettes among electronic cigarette users: A cross‐sectional analysis of the International Tobacco Control Smoking and Vaping (ITC 4CV) England Survey. Addiction, 118(7), 1359–1369.

Other references

Barrington-Trimis JL, Urman R, Berhane K, et al. (2016) E-Cigarettes and Future Cigarette Use. Pediatrics. 2016, 138(1).

Collier, R. (2017). E-cigs have lower levels of harmful toxins. 2017.

Liu G, Wasserman E, Kong L, Foulds J. (2017) A comparison of nicotine dependence among exclusive E-cigarette and cigarette users in the PATH study. Prev Med. 2017 104 86–91.

Marques, P., Piqueras, L. & Sanz, MJ. (2021) An updated overview of e-cigarette impact on human health. Respir Res 2021, 22:151.

Strong DR, Pearson J, Ehlke S, et al. (2017) Indicators of dependence for different types of tobacco product users: descriptive findings from wave 1 (2013–2014) of the population assessment of tobacco and health (PATH) study. Drug Alcohol Depend. 2017 178 257–66.

Action on Smoking and Health (2022). Use of e-cigarettes among adults in Great Britain.

Centre for Disease Control and Prevention (2023) About Electronic Cigarettes (E-Cigarettes)

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