The effects of e-cigarette visual appearance on craving and withdrawal symptoms in abstinent smokers

Cue Reactivity to Electronic Cigarettes: A Systematic Review

Cue reactivity to Electronic Nicotine Delivery Systems (ENDS) has been studied by several researchers, yet the variability in user types (smokers, former smokers, dual users, exclusive ENDS users) and ENDS designs used between the studies may have undermined consistent results. This systematic review aims to give an overview of ENDS cue reactivity and how smoking status and device design may moderate this. A systematic search of Medline, Embase, Web of Science, PubMed and Cochrane was completed. All studies which reported findings on reactivity to ENDS cues in the form of craving or desire for ENDS or cigarettes, attention to cue, delay of gratification or economic decisions were included. Exclusion criteria were non-human subjects, non-adult participants or participants with comorbidities. Literature selection was carried out by 2 independent reviewers. The risk of bias and study quality were assessed using tools developed by Cochrane, BMJ and NHLBI. A total of 711 papers were screened and 22 studies were included in the current review. Study design, research question(s), population of interest, number of participants, dependent variable(s), ENDS generation and nicotine content used and study results were extracted. ENDS cues reliably induced ENDS craving, with no clear moderation by smoking status and no apparent moderation by device generation. In about half of the studies, ENDS cues induced craving for conventional cigarettes. Most studies used a smoker sample, thus limiting the conclusions that can be drawn on the moderation of cue reactivity by smoking status. The quality varied among studies but comparing the findings against the outcomes of only high-quality studies did not yield any different results. The results of this review support the notion of cue reactivity to ENDS, identifies gaps in current research on different user types and implies that ENDS design iterations have little impact on cue reactivity.

Motivated attention to stimuli related to social networking sites: A cue-reactivity study

BACKGROUND AND AIMS

It has been argued that similar to addictive behaviors, problematic Social Network sites use (PSNSU) is characterized by sensitized reward processing and cue-reactivity. However, no study to our knowledge has yet investigated cue-reactivity in PSNSU. The present study aims at investigating cue-reactivity to Social Network sites (i.e., Facebook)-related visual cues in individuals identified as problematic vs. non-problematic Facebook users by the Problematic Facebook Use Scale.

METHODS

The Event-Related Potentials (ERPs) were recorded during the passive viewing of Facebook-related, pleasant, unpleasant, and neutral pictures in 27 problematic and 26 non-problematic users. Moreover, craving for Facebook usage was collected using a Likert scale.

RESULTS

Despite problematic users were more likely to endorse higher craving than non-problematic ones, Facebook-related cues elicited larger ERP positivity (400-600 ms) than neutral, and comparable to unpleasant stimuli, in all Facebook users. Only in problematic users we found larger positivity (600-800 ms) to pleasant than unpleasant cues and higher craving to be related with lower later positivity (800-1,000 ms) to pleasant and unpleasant cues.

DISCUSSION

Regardless of whether Facebook usage is problematic or non-problematic, Facebook-related cues seem to be motivationally relevant stimuli that capture attentional resources in the earlier stages of "motivated" attentional allocation. Moreover, our results support the view that in higher-craving problematic users, reduced abilities to experience emotions would be the result of defective emotion regulation processes that allow craving states to capture more motivational/attentional resources at the expense of other emotional states.

Effectiveness of Non-Nicotinic E-Cigarettes to Reduce Cue- and Abstinence-Induced Cigarette Craving in Non-Treatment Seeking Daily Dependent Smokers

RATIONALE

Electronic cigarettes (e-cigarettes) are potential tools for smoking cessation because they deliver nicotine and simulate smoking behaviors. The contribution of sensorimotor versus pharmacological substitution is unknown.

OBJECTIVES

To evaluate whether non-nicotinic e-cigarettes, used alone or with nicotine lozenges, can attenuate cigarette craving following visual cue presentation or acute (3 h post ad-lib use) abstinence in dependent daily smokers.

METHODS

Following overnight (12 hours) abstinence, 41 daily smokers were exposed to 4 experimental conditions on separate days: (i) tobacco cigarettes (CIG); (ii) non-nicotinic e-cigarettes with placebo lozenges (EPL); (iii) non-nicotinic e-cigarettes with 4 mg nicotine lozenge (ENL); and (iv) 4 mg nicotine lozenge (NL). Cigarette craving was assessed following presentation of neutral and smoking cues at various time points using the Brief Questionnaire of Smoking Urges (QSU-B) and visual analog scales (VAS).

RESULTS

All experimental conditions significantly reduced participants' baseline overnight abstinence cigarette craving. ENLs and NLs attenuated smoking-cue-induced cravings to a greater extent than CIGs, where cravings were significantly higher with CIGs compared to ENLs [mean difference (MD) ± standard error (SE) in QSU-B = 3.2 ± 0.84, P = 0.002; VAS = 12.7 ± 2.7, P < 0.0005] and NLs [MD ± SE in QSU-B = 2.7 ± 0.92, P = 0.031; VAS = 8.1 ± 2.3, P = 0.005]. Craving responses to cues after 3 h were higher after smoking CIGs compared to ENLs [MD ± SE in QSU-B = 3.9 ± 1.4, P = 0.047; VAS = 14.1 ± 3.6, P = 0.002] and NLs [MD ± SE in QSU-B = 3.2 ± 1.1, P = 0.046; VAS = 9.7 ± 3.1, P = 0.017].

CONCLUSIONS

Behavioral simulation of smoking with or without nicotine reduces nicotine craving. Compared to cigarettes, ENL with NL or NL alone attenuates cigarette craving over time. Future clinical trials should evaluate the combination of ENL and NL as a method for smoking reduction or cessation.

TRIAL REGISTRATION

NCT02108626.

E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers, including relapse in former smokers: umbrella review, systematic review and meta-analysis

OBJECTIVE

To review and summarise the current evidence on the uptake of combustible cigarette smoking following e-cigarette use in non-smokers-including never-smokers, people not currently smoking and past smokers-through an umbrella review, systematic review and meta-analysis.

DESIGN

Umbrella review, systematic review and meta-analysis.

DATA SOURCES

PubMed, Scopus, Web of Science, PsychINFO (Ovid), Medline (Ovid) and Wiley Cochrane Library up to April 2020.

RESULTS

Of 6225 results, 25 studies of non-smokers-never, not current and former smokers-with a baseline measure of e-cigarette use and an outcome measure of combustible smoking uptake were included. All 25 studies found increased risk of smoking uptake with e-cigarette exposure, although magnitude varied substantially. Using a random-effects model, comparing e-cigarette users versus non-e-cigarette users, among never-smokers at baseline the OR for smoking initiation was 3.25 (95% CI 2.61 to 4.05, I2 85.7%) and among non-smokers at baseline the OR for current smoking was 2.87 (95% CI 1.97 to 4.19, I2 90.1%). Among former smokers, smoking relapse was higher in e-cigarette users versus non-users (OR=2.40, 95% CI 1.50 to 3.83, I2 12.3%).

CONCLUSIONS

Across multiple settings, non-smokers who use e-cigarettes are consistently more likely than those avoiding e-cigarettes to initiate combustible cigarette smoking and become current smokers. The magnitude of this risk varied, with an average of around three times the odds. Former smokers using e-cigarettes have over twice the odds of relapse as non-e-cigarettes users. This study is the first to our knowledge to review and pool data on the latter topic.

PROSPERO REGISTRATION NUMBER

CRD42020168596.

Well-being and harm reduction, the consolidated reality of electronic cigarettes ten years later from this emerging phenomenon: A narrative review

Tobacco use is the greatest threat to public health worldwide, killing more than seven million people annually. This paper, about 10 years after the first review on electronic cigarettes, analyses the evolution that this tool has had in these years. It concludes with comments on the significance of the research and why it constitutes an original contribution. We searched PubMed (National Library of Medicine), and PsycINFO (Ovid) (2006-2020) for studies on e-cigarettes (harms and benefits, e-cigarette use, craving and smoking cessation) and smoking cessation treatment (smoking cessation treatment or varenicline or tobacco cessation or reduction or bupropion or NRT or behavioral treatment or ecigarette) and evidence suggests that they may effective as smoking cessation tool and may be less harmful alternatives to combustible cigarette smoking. Consequently, e-cigarettes could be considered as an applicable instrument for Tobacco Harm Reduction (THR) and smoking cessation.

Short Bouts of Physical Activity Are Associated with Reduced Smoking Withdrawal Symptoms, but Perceptions of Intensity May Be the Key

The primary aim of this study was to assess the effectiveness of a short bout (10 min) of moderate-intensity exercise to reduce withdrawal symptomatology, craving and negative affect; while the secondary aim was to assess how the effectiveness of a short bout of moderate exercise can be modulated by the perception of intensity in physically active and low-activity smokers. Fifty low-activity and physically active smokers were recruited (24 male and 26 female) and randomized in three different conditions. Prescribed (objective) moderate intensity (OBJ) and perceived moderate intensity (PER), and passive waiting (PW). After the intervention (T3), smokers reported less desire to smoke in the PER (p < 0.001) and OBJ (p < 0.001) conditions, relative to the PW condition. At T3 smokers in the PER condition reported less negative affect than smokers in the PW condition relative to the baseline (T1) (p < 0.007). Further, smokers in the PER condition reported less negative affect than smokers in the PW condition (p < 0.048). Physically active (PA) smokers perceived less exertion than low-activity (LA) smokers, and the effects were stronger in the PER condition relative to OBJ. Generally, our results suggest that a short bout of moderate exercise helps both LA and PA smokers. These findings provided a novel insight into the psychological mechanisms that affect the efficacy of the exercise in smoking cessation and suggest that exercise should be tailored according to individual perception of intensity.

A qualitative study of the views about smoking, licensed cessation aids and e-cigarettes in people with schizophrenia spectrum disorders

Smoking prevalence remains high among people with a mental health condition compared to those without. Understanding people's motivation to quit and their views of smoking cessation support may help to develop future interventions. We conducted a qualitative study to explore the perceptions of 30 people with schizophrenia spectrum disorders who were current smokers, about smoking traditional cigarettes, the appeal of licensed medicines and e-cigarettes for smoking cessation or smoking reduction. The experiences of participants who were motivated to quit were compared with those who were not motivated to quit. Findings suggest traditional cigarettes were pleasurable and licensed cessation aids and e-cigarettes unappealing to participants who were unmotivated to quit. Whereas nicotine replacement products and e-cigarettes may be an appealing smoking cessation or reduction strategy for those motivated to quit. There is a need to find ways of making traditional cigarettes less appealing and alternative less harmful nicotine products (licensed and unlicensed) more appealing and accessible to this group of high risk smokers.

Twenty-four-hour subjective and pharmacological effects of ad-libitum electronic and combustible cigarette use among dual users

BACKGROUND AND AIMS

Relative pharmacological effects of e-cigarettes and cigarettes during 24 hours of ad-libitum use have not been described. In this study, 24-hour blood plasma nicotine concentrations and 48-hour subjective effects with use of cigarettes and e-cigarettes were measured among dual users.

DESIGN

Two-arm within-subject cross-over design with preferred e-cigarette or cigarette ad-libitum use over 48 hours.

SETTING

Hospital research ward in San Francisco, California, USA.

PARTICIPANTS

Thirty-six healthy dual users of e-cigarettes and cigarettes (n = 8, 25% females).

MEASUREMENTS

Twenty-four-hour blood plasma nicotine and cotinine concentrations and 48-hour self-reported nicotine withdrawal symptoms and rewarding effects.

FINDINGS

Analyses used analysis of variance (ANOVA)-based mixed models with order of product (e-cigarette or cigarette) and product type (combustible cigarette or type of e-cigarette) as fixed effects, and subject as a repeated effect. During a 24-hour period, e-cigarettes produced lower nicotine exposure than cigarettes for the majority of users, although 25% received more nicotine from e-cigarettes, which was predicted by more frequent e-cigarette use or greater dependence. Compared to cigarette smoking, nicotine exposure for variable-power tank users was similar, while cig-a-like (t₍₃₀₎  = 2.71, P = 0.011, d = 0.745) and fixed-power tank users (t₍₃₀₎  = 3.37, P = 0.002, d = 0.993) were exposed to less nicotine. Cigarettes were rated higher than e-cigarettes on some desirable subjective effects (e.g. psychological reward, t₍₃₂₂₎  = 7.24 P < 0.001, d = 0.432), but withdrawal symptom reduction was comparable. No differences were found between e-cigarette types, but Bayes factors indicate that these measures were insensitive.

CONCLUSIONS

During a 24-hour period in a hospital setting in the United States, nicotine exposure for dual users of e-cigarettes and cigarettes was similar when using cigarettes or variable-power tank devices only but was lower for those using cig-a-like or fixed-power devices only. Despite lower nicotine levels, all types of e-cigarette were effective in preventing withdrawal symptoms. E-cigarettes were rated less rewarding than cigarettes.

Tobacco smoking, related harm and motivation to quit smoking in people with schizophrenia spectrum disorders

This narrative review focuses on the topic of tobacco smoking amongst people with schizophrenia spectrum disorders. We searched PubMed, PsycInfo and Scopus databases for schizophrenia spectrum disorders and smoking and included articles about the epidemiology of tobacco smoking in people with schizophrenia spectrum disorders, examining the relationship between smoking and mental health. This narrative review describes that a higher prevalence, frequency and impact of both high nicotine dependence and its harmful effects in patients with schizophrenia spectrum disorders compared with those in the general population. Despite several existent theories, the reasons for high smoking rates, the high dependence on nicotine and severity of nicotine withdrawal symptoms are not fully understood. The main aim of this paper is to inform mental health personnel and particularly clinical and health psychologists about the impact and role of tobacco smoking for smokers with schizophrenia spectrum disorders.

Early Subjective Sensory Experiences with "Cigalike" E-cigarettes Among African American Menthol Smokers: A Qualitative Study

Introduction

Despite smoker interest in e-cigarettes as a harm reduction or cessation aid, many smokers prematurely discontinue vaping after trying a product. This study explored the role of early subjective sensory experiences in vaping persistence and desistance.

Methods

African American menthol cigarette smokers aged ≥18 years (N = 15; M = 54.1 years; SD = 8.2), motivated to quit smoking, and interested in trying e-cigarettes were recruited in Washington, DC. Participants were followed for 3 weeks and provided menthol cigalike e-cigarettes after Week 1. Participants completed three interviews about their vaping experiences. Thematic analysis of responses was designed to understand the sensory aspects of vaping.

Results

During the first 2 weeks of vaping, four participants reported a positive vaping experience while 11 reported decreased satisfaction. Salient sensory attributes of dissatisfaction included poor taste, insufficient throat hit, difficulty pulling, and a lack of "whole body" satisfaction compared to their preferred cigarette brand.

Conclusions

The sensory experiences with a specific cigalike e-cigarette were related to vaping persistence and desistence. Although this was a small volunteer sample of African American menthol smokers motivated to quit smoking, 27% (N = 4) of participants with a positive vaping experience continued using the product, while 73% (N = 11) of participants' vaping experience was unsatisfactory across several experiential categories. In future research of e-cigarettes' efficacy as a smoking cessation or reduction aid, both device characteristics and smokers' expectations for these devices should be considered, so vapers do not expect the same taste sensations, throat sensations, and "whole body" satisfaction as they experienced with their menthol cigarettes.

Implications

The subjective sensory experiences associated with initial e-cigarette product use are associated with use patterns. Subjective sensory experiences may also help understand the differences in the appeal, satisfaction, and harm-reduction potential of the rapidly evolving diverse types of products emerging in the marketplace. How products meet the sensory needs of smokers wanting to switch or quit smoking may influence adherence and success rates.

Young adults report increased pleasure from using e-cigarettes and smoking tobacco cigarettes when drinking alcohol

BACKGROUND

Cigarettes share a high rate of co-use with alcohol, particularly among young adults. Studies have demonstrated greater perceived pleasure from smoking cigarettes when drinking alcohol. However, little is known about co-use of electronic cigarettes (e-cigs) and alcohol. The current study sought to compare extent of use and perceived pleasure from cigarettes and e-cigs when drinking alcohol.

METHODS

Young adult bar patrons in California cities (San Diego, Los Angeles, and San Francisco) were recruited in 2015-16 using randomized time-location sampling. Participants completed cross-sectional surveys in bars, reporting the percent of cigarette smoking/e-cig use that occurred under the influence of alcohol, and reported if pleasure from smoking cigarettes/using e-cigs changed when drinking alcohol. Analyses are limited to participants reporting current (past 30-day) use of cigarettes, e-cigs, and alcohol (N = 269; M age = 24.1; 40.1% female, 36.1% Non-Hispanic White).

RESULTS

Participants reported a greater percentage of cigarette smoking compared to e-cig use under the influence of alcohol (cigarettes M = 63.6%; e-cigs M = 46.7%; p < .001). Participants also reported increased pleasure both from smoking cigarettes (M = 3.9; [compared to midpoint of scale 3 - "no change"] p < .001) and using e-cigs (M = 3.3; p < .001) when drinking alcohol. The increase in pleasure was more pronounced for cigarettes compared to e-cigs (p < .001).

CONCLUSIONS

Drinking alcohol is associated with increases in perceived rewarding effects of both cigarettes and e-cigs and thus may increase their abuse liability. This effect may be stronger for cigarettes, which could be an important barrier to switching completely from smoking cigarettes to using e-cigs, or quitting both entirely.

Autonomic stress reactivity and craving in individuals with problematic Internet use

The link between autonomic stress reactivity and subjective urge/craving has been less systematically examined in behavioral addictions (i.e. problematic Internet use) than in substance use disorders. The present study investigated whether problematic Internet users (PU) show enhanced autonomic stress reactivity than non-PU, indexed by lower Heart Rate Variability (HRV) and higher Skin Conductance Level (SCL) reactivity during the Trier Social Stress Test (TSST), whether greater reactivity is related to stronger Internet craving, and whether problematic Internet usage is associated with some dysfunctional psychological features. Based on their Internet Addiction Test scores, participants were divided into PU (N = 24) and non-PU (N = 21). Their heart rate and skin conductance were continuously recorded during baseline, social stressors, and recovery. Craving for Internet usage were collected using a Likert scale before and after the TSST. The SDNN, an overall measure of HRV, was significantly lower in PU than non-PU during baseline, but not during and after stressful task. Furthermore, only among PU a significant negative correlation emerged between SDNN during recovery and craving ratings after the test. No group differences emerged for SCL. Lastly, PU endorsed more mood, obsessive-compulsive, and alcohol-related problems. Our findings suggest that problems in controlling one’s use of the Internet may be related to reduced autonomic balance at rest. Moreover, our results provide new insights into the characterization of craving in PIU, indicating the existence of a relationship between craving for Internet usage and reduced autonomic flexibility.

Qualitative analysis of young adult ENDS users' expectations and experiences

OBJECTIVES

Despite extensive research into the determinants of electronic nicotine delivery system (ENDS) uptake, few studies have examined the psychosocial benefits ENDS users seek and experience. Using a consumer ritual framework, we explored how ENDS users recreated or replaced smoking practices, and considered implications for smoking cessation.

DESIGN

In-depth interviews; data analysed using thematic analysis.

SETTING

Dunedin, New Zealand.

PARTICIPANTS

16 young adult ENDS users (age M=21.4, SD=1.9; 44% female).

RESULTS

Participants reported using different ENDS to achieve varying outcomes. Some used 'cigalikes' to recreate a physically and visually similar experience to smoking; they privileged device appearance over nicotine delivery. In contrast, others used personally crafted mods to develop new rituals that differentiated them from smokers and showcased their technical expertise. Irrespective of the device they used, several former smokers and dual users of cigarettes and ENDS experienced strong nostalgia for smoking attributes, particularly the elemental appeal of fire and the finiteness of a cigarette. Non-smoking participants used ENDS to maintain social connections with their peers.

CONCLUSIONS

Participants used ENDS to construct rituals that recreated or replaced smoking attributes, and that varied in the emphasis given to device appearance, nicotine delivery, and social performance. Identifying how ENDS users create new rituals and the components they privilege within these could help promote full transition from smoking to ENDS and identify those at greatest risk of dual use or relapse to cigarette smoking.

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.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

Nicotine Replacement, Topography, and Smoking Phenotypes of E-cigarettes

OBJECTIVES

Little is known about the degree of nicotine replacement across first-generation e-cigarette brands, how e-cigarettes are used, and if there is variation across brands in relevant smoking phenotypes. The objective of this project was to collect data that are critical to better understanding, use, and exposure when using e-cigarettes, which may then inform clinical trials and tobacco regulatory policy.

METHODS

Twenty-eight cigarette smokers were randomized to use one of 5 popular brands of e-cigarettes for a 10-day study. Day 1 (own cigarette brand) data established baseline levels for cotinine, carbon monoxide (CO), topography, cigarette liking, withdrawal, and craving. Participants returned on Days 5 and 10 to reassess these measures while exclusively using e-cigarettes.

RESULTS

Compared to cigarette smoking, e-cigarettes provided significantly lower nicotine levels (25%-50%), reduced CO exposure, and lower ratings of liking (p < .05). Topography significantly differed between cigarette and e-cigarette sessions (p < .05). All brands significantly reduced withdrawal and craving (p < .05). There were no significant brand differences in outcome measures associated with exposure or use.

CONCLUSIONS

E-cigarettes are not liked as much as cigarettes, provide significantly lower nicotine replacement, reduce CO exposure, and mitigate withdrawal and craving. The patterns of use significantly differ compared to cigarette smoking.