There were nine included studies, three of which focused on e-cigarettes (Table 2) and six on NRT (Table 3). We did not identify any qualitative studies of smokeless tobacco use that had a focus on distinct SES categories. Most participants across the studies were either smokers or ex-smokers. All included studies focussed specifically on groups that were socioeconomically disadvantaged in some way. We found no eligible studies that focussed on clearly identifiable groups of other SES, suggesting there is gap in existing research in terms of qualitative research that looks across SES groups or which focuses on understanding experiences and perceptions of NCNPs in more advantaged groups. Most studies recruited from areas of the UK deemed to be either socioeconomically disadvantaged or ‘working class’ [30, 50–53], a term commonly used in the UK to describe lower SES groups [54]. One study [55] used the UK Townsend Deprivation Index, while three others [46–48] (from the same dataset) recruited participants from welfare service users in Australia. Many studies identified in the original search were not included on the basis that they did not contain references to NCNP or were focussed on some other aspect of disadvantage that was not related to SES.
Table 2: Included e-cigarettes studies
Study
|
Location
|
Participants
|
Methods
|
SES
|
Study period
|
Study aims
|
Rooke et al 2016
|
Central Scotland
|
N=64, smokers and recent ex-smokers, mean age 36, 33 female
|
Interviews and focus groups
|
Recruitment from socially disadvantaged areas
|
2013-2014
|
To explore the understandings and experiences of e-cigarettes among disadvantaged smokers and recent ex-smokers
|
Rowa-Dewar et al 2017
|
Five communities in Edinburgh, UK
|
N=25, smokers and some ex-smokers, parents of young children, 22-47yo, 22 female
|
Interviews
|
Recruitment from socially disadvantaged areas
|
2013-2014
|
To explore the uses and perceptions of e-cigarettes by disadvantaged parents, especially in relation to temporary smoking abstinence in the home.
|
Thirlway 2016
|
North West Durham, North-East England, UK
|
N=41, smokers and ex-smokers, 18-75yo, mean age 42, 28 men
|
Ethnographic observation, including field notes and interviews
|
Recruitment from predominantly working class sites
|
2012-2015
|
To explore the potential of e-cigarettes to address health inequalities.
|
Table 1: Included e-cigarettes studies
Table 3: Included NRT studies
Study
|
Location
|
Participants
|
Methods
|
SES
|
Study period
|
Study aims
|
Atkinson et al. 2013
|
Nottingham, UK
|
36, smokers, parents of young children, 16yo and over, 28 female
|
Interviews
|
Recruitment from socially disadvantaged areas
|
2009
|
To explore the uses and perception of NRT by disadvantaged parents, especially in relation to temporary smoking abstinence in the home.
|
Bonevski et al 2011
Bryant et al 2010
Bryant et al 2011
|
New South Wales, Australia
|
32, smokers, 16yo+, 22 female
|
6 focus groups of 3-8
|
Users of community welfare services
|
2008-2009
|
Overall study aims: To explore the barriers and opportunities for smoking cessation for disadvantaged smokers.
|
Roddy et al 2006
|
Nottingham ,UK
|
39, smokers, 27-77yo, 33 male
|
9 Focus groups of 2-7
|
Local indicator of SES (Townsend score)
|
Unclear
|
To identify barriers or motivators among disadvantaged smokers to accessing smoking cessation services.
|
Wiltshire et al 2003
|
Two sites in Edinburgh, UK
|
100 smokers, 25-40yo, 50 female
|
Interviews
|
Recruitment from socially disadvantaged areas
|
1999-2000
|
To investigate the perceptions and experiences of quitting among smokers from disadvantaged areas
|
Table 2: Included NRT studies
Although the studies contained relevant data for either e-cigarettes or NRT and there was only some overlap in discussion between those two types of NCNP in any study, the ultimate lines-of-argument analysis for each NCNP were relatively similar with many themes occurring in both strands of analysis and being straightforwardly translated into each other. For this reason we have largely considered NRT and e-cigarettes together (where this was not the case, we are explicit in the results). The studies rarely differentiated between the different types and models available of e-cigarettes (e.g. cigalike, tanks/mods) or NRT (e.g. gum, patches, inhaler). Hence, by necessity, we also had to treat each NCNP type largely collectively. However, it should be noted that e-cigarettes and NRT are both broad categories and the types of product available for both are becoming increasingly diverse [21, 56].
We categorised our final lines-of-argument into three overall views on the prospects of NCNP for harm reduction: ‘pessimistic’, ‘optimistic’ and ‘uncertain’ (Table 4). Full details of the coding process can be found in the Supplementary File. Pessimistic results, which reflected a general lack of enthusiasm or perceived ability to use NCNP to replace smoking, were the most common results and so are discussed first. Optimistic findings, which relayed enthusiasm for using NCNP to replace or reduce smoking, were the next most common result so are discussed next. Finally, we discuss the least common category; views and experiences that seemed ‘uncertain’ about NCNP, especially in terms of the potential for harm reduction or cessation. We note, at the outset, that there were significantly more optimistic findings relating to e-cigarettes than to NRT, which appeared to reflect different modes of use and understandings of relative harm.
Table 4: Final lines-of-argument synthesis
Pessimistic (more common findings)
|
Uncertain (more common findings)
|
Optimistic (less common findings)
|
Social, cultural and economic circumstances of socioeconomically disadvantaged smokers not conducive to NCNP uptake
|
NCNP positioned as useful for smoking reduction but not necessarily smoking cessation
+
NCNP alone perceived to have limited potential for smoking harm reduction
|
Social, cultural and economic circumstances of socioeconomically disadvantaged smokers can be conducive to NCNP uptake
|
NCNP do not carry enough ‘relative advantage’ over smoking
|
NCNP have some ‘relative advantage’ over cigarettes
|
Lack of clear information about relative harm of NCNP
|
Accepted knowledge about relative harm and NCNP
|
Pessimistic views
This section discusses the pessimistic views towards NCNP that were identified across the studies, focusing on: (i) how social, cultural and economic circumstances often seemed to deter NCNP use; (ii) explaining why NCNP were considered as having little relative advantage over smoking; and (iii) perceptions of a lack of information about NCNP.
(i) Social, cultural and economic circumstances of socioeconomically disadvantaged smokers are not conducive to NCNP uptake. Social and cultural circumstances in which smoking was perceived as a normal part of everyday life was a feature of most studies. Stress was a common experience mentioned by participants across the studies and some appeared to feel resigned to returning to smoking after periods of exclusive e-cigarette use. For example, a participant from Rooke et al [49: e63] talked about switching back to combustible tobacco, attributing this directly to experiencing stress:
Because […] there’s a wee bit too much stress in my life at the moment that I had to go back on the cigarettes. (Female, 47, smoker)
The reliability of combustible tobacco compared to NCNP, and its retention as a last resort, was similarly evident in a participant from Thirlway’s [30: 109] study, who was;
A serial quitter and had tried everything to give up; she bought an e-cigarette … and this went well until “it rolled off the table and broke” and she reverted to the pouch of illicit rolling tobacco tucked into the front pocket of her tabard
Stress therefore made it difficult for NCNP to take hold for many of the participants in the studies.
Gender appeared to intersect with socioeconomic disadvantage to shape experiences in several studies. For example, female participants in Thirlway’s study [30] frequently described prioritising family caretaking over their own wellbeing, leaving little time for self-care, such as smoking reduction. Additionally, Thirlway [30] noted that e-cigarette use in a working class area in north-east England appeared to be dominated by young men who appeared to be attracted to the novelty and gadgetry of the devices, with some women seeming reluctant to visit vape shops where young men congregated.
Thirlway [30] also identified a ‘working-class hedonism’ throughout her study, e.g. “them at Greendale [middle class area] haven’t enjoyed themselves the way us lot have – I’ve no regrets” (p. 110, male, 47, smoker) . Thirlway observed that other young men in her study felt vaping did not fit with a ‘hedonistic’ masculinity that valued carefree consumption. Hence, there were variations in local responses to, and views of, e-cigarettes, both between men and women and among men.
Experiences of unemployment also influenced attitudes towards NCNP. Atkinson et al [50] and Wiltshire et al [52] noted that participants rarely encountered situations of enforced temporary abstinence at home or work due to unemployment . For example a male (smoker) participant in Wiltshire et al said of him and his partner: “[We’re] not comfortable living here... I’m unemployed... Stress levels have been very high [and] we have noticed we smoke a lot more” (p. 299). Atkinson et al and Wiltshire et al both suggest that encountering such restrictions is more common for more affluent individuals in higher grades of employment, and for whom smoking reduction and cessation then becomes expected and normalised.
The perceived high price of NCNP, along with a concern about not getting value for money if they turned out not to help smoking cessation or reduction, recurred throughout most of the studies. Financial concerns were particularly highlighted by participants in Thirlway’s [30] study:
Although £10 would buy a starter tank and e-liquid, smokers like Martin could get a week's worth of illicit rolling tobacco for the same money and could not risk such a large outlay on something that might not ‘work’ for him (p. 108).
Furthermore, Thirlway noted that people were likely to revert to cigarettes when their e-cigarette broke, rather than seek a replacement (as illustrated in earlier extract). Similarly, Wiltshire et al [52] and Roddy et al [55] found that cigarettes were easily obtainable through informal networks when money was tight, suggesting that the financial disincentive to smoke was not as great as might be expected in a context of high tobacco taxation.
(ii) NCNP do not carry enough ‘relative advantage’ over smoking or other harm reduction products. When discussing NRT, many of the participants explained that it had an unpleasant taste – reflecting findings by Dawkins et al [20] – or said that they felt it did not work as intended. Additionally, some participants explained that they enjoyed smoking and were unconcerned about continued smoking.
I know it’s bad for me and everything like that, but I do enjoy it. (Female, smoker) (Wiltshire et al: 297 [52])
I just like fags. I just like the taste of fag. (Male, 20, smoker) (Rooke et al: 063 [51])
While NRT represented a complete break from smoking actions in ways that sometimes seemed incompatible with participants’ stress relief rituals, e-cigarettes were sometimes experienced as unsettling precisely because of their similarity to smoking. For example, some participants noted that switching to an e-cigarette did not feel like quitting and that the similarities could potentially continue an addiction and/or habit that was perceived negatively:
I don’t feel like I’ve stopped smoking, I just feel like I smoke them instead. (Female, 47, ex-smoker) (Rooke et al: e63 [51])
It’s not getting rid of the habit. [...] I’m still trying to persuade my husband to go on [nicotine replacement] patches, because I’m like, honestly, you’ve got to stop with that part of it [simulating smoking action]. (Female, 40, smoker) (Rowa-Dewar et al: 18 [53])
Likewise, Thirlway [30] found that some people regarded addiction as the primary ‘deviance’ so expressed some unease about e-cigarettes, given the continuation of nicotine use.
(iii) Lack of clear information about relative harm of NCNP. Relatedly, many of the studies reported uncertainty about the relative harms of NCNP, often centring on the continuation of nicotine consumption and the potential of becoming addicted to something new.
I kind of understand it [NRT] … but then on the other side of it I think because it’s nicotine replacement so how is it gunna help you stop if it’s still giving you the nicotine. (Female, 25-34, smoker) (Atkinson et al 2013: 4 [50])
Studies on e-cigarettes also found some participants to be unsure about the health risks of e-cigarettes.:
I don’t trust the electronic cigarettes, I just...I don’t think there’s been enough research on them. (Male, 39, smoker) (Rowa-Dewar et al: 17 [53])
Some of the participants in Rooke et al [51] were particularly distrustful of e-cigarettes that were not sold through official retailers such as Boots, citing unknown and possibly dangerous ingredients. Atkinson et al [50] believed that their data suggested the negative effects of environmental tobacco smoke had come to be underestimated by participants due to a lack of knowledge, and contributed to lack of uptake of less harmful NRT in the homes of those smokers with children.
Optimistic views
Despite a general lack of enthusiasm for all forms of NCNP across the nine studies, there were also some more positive attitudes to e-cigarettes within all studies. These attitudes were informed by: (i) accounts of social, cultural and economic circumstances; (ii) perceptions of the relative advantages of NCNP; and (iii) accepted knowledge about the reduced harms of NCNP.
(i) Social, cultural and economic circumstances of socioeconomically disadvantaged smokers can be conducive to NCNP uptake. In contrast to e-cigarettes not fitting with a ‘hedonistic’ identity, their novelty technology also appeared to be an attractive point for some young men who used the devices to develop a ‘vaper’ identity through expertise and owning the latest equipment:
When last I saw Adam (30, smoker), he was very proud of his latest, fourth-generation e-cigarette with wireless connectivity, and he told me that several of his friends had followed his example. (Thirlway: 108 [30])
By examining the everyday tactics of buying and using e-cigarettes in a working class community, Thirlway discovered that some smokers used the ‘informal e-cigarette economy’ to avoid higher prices and so resist the more middle-class lifestyle and hobbyist approaches to e-cigarette use. These working class vapers were able to cast their use as functional rather than recreational and so “demonstrate moral worth in relation to the moral problems of addiction and expenditure on the self” (p. 111).
This evidence of a thriving informal economy in Thirlway’s paper indicates the importance of community-led distribution and exchange mechanisms for e-cigarettes and associated items such as e-liquids, which has emerged due to the social aspects of vaping [57]. Aspects of Rooke et al’s study [51] refute this, indicating that smokers prefer ‘trustworthy’ high street retailers and avoid informal retail sources. These differences may be explained in part by the recruitment methods in the two studies. Many of the participants in Rooke et al were recruited through smoking cessation groups and so may have been predisposed to e-cigarette products that followed licensed NRT in being ‘official’ and endorsed by reputable retailers. In contrast, Thirlway’s participants were approached through general community settings and so not necessarily interested in cessation.
Gender dynamics were further evident in Thirlway’s [30] study as men with serious health problems were able to enrol e-cigarette use in “local constructions of masculinity” through being a “badge of moral intent” (p. 110) to take responsibility for improving health outcomes. Despite this intent, Thirlway observed these men continuing to smoke, or at least being in possession of smoking paraphernalia, and was unsure whether their vaping went beyond a marker of moral identity to signify significant behaviour change.
In contrast to findings suggesting NCNP were too expensive [30, 52, 55], Rowa-Dewar et al [53] found one instance of e-cigarette use being described as saving money for a couple compared to smoking.
(ii) NCNP have some ‘relative advantage’ over cigarettes. Also in contrast to pessimistic findings in the papers about the embodied similarities of smoking and vaping impeding use, Rooke et al [51] and Rowa-Dewar et al [53], both found that the embodied similarities between vaping and smoking could also be viewed positively. For one of Rooke et al’s [51] participants:
They’re more satisfying. Much more satisfying. I think because, see when you take a puff, it actually feels like, you used to get that kind of hit off a cigarette when you took a puff off the cigarette, you get that sensation from the e-cig. (Female, 42, ex-smoker) (p. e62)
(iii) Accepted knowledge about relative harm and NCNP. Further contrasting aspects within included studies were that Rooke et al [51] and Rowa-Dewar et al [53] found some participants to be well informed about the relative harm of vaping compared to smoking, so suggested that e-cigarettes carried a clear relative advantage and were generally healthier than smoking:
You’re still smoking nicotine, but you’re not smoking tar and you’re not making your lungs… you’re not making your lungs get covered in tar. (Male, 20, smoker) (Rooke et al: e63 [51])
This suggests that the similarity of the experience of vaping to e-cigarettes is viewed as both an attraction and a draw-back, depending on the outlook and preferences of the smoker.
Uncertain views
Uncertain views of NCNP were characterised by: (i) NCNP being useful for cutting down on smoking but not necessarily stopping; and (ii) NCNP have limited potential for cessation if other drivers for cessation were not present.
(i) NCNP positioned as useful for smoking reduction but not necessarily smoking cessation. Both the e-cigarette and NRT studies reported that users felt the products could be useful for smoking reduction but not necessarily for complete cessation:
I’d go on the patches … and the inhaler … Then I’d cut down slowly as much as I could. (Female, 35-44, smoker) (Atkinson et al: 5 [50])
I’m going to buy one of they new electronic fags […] Because a few of my friends have got them, and they do work, do you know what I mean. It’s like you can have a morning fag, and like a night time fag, but that helps you through the day if you’re out, [...] so I’m going to get one of them. (Female, 28, smoker) (Rowa-Dewar et al: 15 [53])
There were some differences between NRT and e-cigarettes when it came to potential harm reduction beliefs. Both Rooke et al [51] and Thirlway [30] noted participants regarded NRT as more obviously a cessation aid than e-cigarettes, as vaping had connotations of recreation. This was reflected in Atkinson et al’s [50] study, which found that NRT was considered a cessation aid and medicinal product. The participants in Atkinson et al [50] were generally negative about the potential for NRT to assist in temporary abstinence in the home. They felt that anything short of complete abstinence was not effective and using NRT while still smoking was ‘cheating’:
Well, I wouldn’t see much point in that [using NRT for temporary abstinence] to be honest if I was, if I was going to stop smoking, if I was going to use something like that I’d want to stop smoking completely, not just in the house. You know, because that way I wouldn’t be cheating going outside for a cigarette. (Female, 16-24, smoker) (p. 5)
One participant in Atkinson et al’s study did successfully use NRT for temporary abstinence in home, but the authors note that this was contrary to the prevailing experience of other participants. Despite these beliefs, many of the participants in Atkinson et al [50] still indicated that they would try NRT sometime in the future to help them quit smoking. The participants in Rowa-Dewar et al’s [53] study of parents who smoke were more optimistic about the potential of e-cigarettes for temporary abstinence in the home:
Handy for you to cut down, because you can use that between … I smoke it in the house. (Female, 28, smoker) (p. 16)
Outside of these two studies, which directly looked at smoking and NCNP use in the home, using NCNP to cut down in homes was not evident in the other papers. Wiltshire et al [52] did mention participants’ desires to cut down on smoking in the home but this was not related to NCNP use.
(ii) NCNP alone perceived to have limited potential for smoking harm reduction. A common theme among all the studies was that NCNP would not work unless people had motivation to quit smoking in the first place. Willpower was frequently mentioned as a more important resource for quitting than NCNP to the extent that some participants dismissed the value of NCNPs altogether:
While ‘patches’ might be used to initially stop smoking, like many interviewees, F35 felt that without ‘the willpower I don’t think they’re going to help you’. (Female, smoker) (Wiltshire et al: 299 [52])
I just don’t see the point. If you’re going to stop, use your willpower, don’t use some silly electronic device. (Female, 36, smoker) (Rowa-Dewar et al: 17 [53])
Building on the previous findings, these uncertain views demonstrated that alongside wider social, cultural and economic circumstances of participants, personal motivation was also a key factor in determining the perceived efficacy of NCNP.