“I’m both smoking and vaping”: A longitudinal qualitative study of US young adults who tried to quit smoking cigarettes by using electronic cigarettes

Abstract

Objective:

To describe how young adults use electronic nicotine delivery systems (ENDS) for smoking cessation and reasons why they may or may not successfully quit smoking.

Methods:

Longitudinal qualitative data were collected annually from 2017 to 2019 for 25 young adult tobacco users (18–29 years old) in California (US) who used ENDS to quit/reduce smoking. Thematic and trajectory analyses were used to identify key within-person and between-person changes in tobacco/nicotine use over time.

Results:

Five types of tobacco use transition were identified among baseline dual users of cigarette and ENDS: Sustained dual use without reduced smoking (n=8), Transition to exclusive daily ENDS use (n=6), Sustained dual use with reduced smoking (n=5), Transition back to exclusive smoking (n=4), and Transition to neither smoking nor vaping (n=2). Participants’ ENDS use behavior varied over time in terms of vaping quantity and device characteristics (e.g., changing nicotine concentrations/flavors, switching between multiple devices). Three themes that related to successfully replacing cigarettes with ENDS were Perceived positive physical effects, Perceived satisfaction and enjoyment, and Context changes. Four themes for unsuccessful replacement were Perceived negative physical discomforts, Perceived addictiveness and harm, Unsatisfactory substitution for cigarettes, and Device malfunction.

Conclusions:

Young adults’ experiences with using ENDS as a smoking cessation aid were highly variable. Adequate nicotine delivery and perceived safety and benefits contributed to successfully reducing or quitting cigarettes. Providing behavioral counseling and standardising ENDS products may enhance cessation for young adults.

INTRODUCTION

Tobacco cessation support is needed for young adults (YAs) aged 18–29 years,¹ a priority population for tobacco control in the US.² Efforts to reduce YA cigarette smoking are complicated by increasing use of non-cigarette tobacco and nicotine products.³ Using multiple products, particularly dual use of cigarettes and electronic nicotine delivery systems (ENDS), is popular among YAs.⁴ There are about 2 million people who report dual use, representing 1–2% of the US adult population.⁵ Prevalence of dual use is highest among YAs (3.0–3.5%) compared to the general adult population (1.7%), with varying levels of exclusive cigarette (2.1–13.2%) and exclusive ENDS (6.4–12.5%) use across YA age sub-groups.⁶ YAs perceive that ENDS are healthier and more convenient to use than cigarettes, and that their day-to-day environment and contexts contribute to dual use.⁷ Although ENDS are not an approved smoking cessation aid in the US, far more YAs use ENDS for smoking cessation than approved nicotine replacement therapy (NRT).⁸ Understanding whether dual use of cigarettes and ENDS is a temporary behavior to facilitate smoking cessation or a sustained behavior which may increase tobacco-related harms is critical to inform policy that balances population-level risks and benefits of ENDS.

Evidence of the effectiveness of ENDS for adult smoking cessation is mixed. A 2021 review of trials and interventions indicated moderate-certainty that ENDS benefited smoking cessation compared to NRT.⁹ Another 2021 review of trials and observational studies showed that ENDS were associated with increased smoking cessation in randomized control trials but not in observational studies, suggesting that ENDS might be effective for smoking cessation as prescription therapy but not as consumer products.¹⁰ Research examining ENDS effectiveness specifically for YA smoking cessation is limited.¹¹ A 2019 review of observational studies could not draw a conclusion because the two relevant studies reported conflicting results among YA smokers who wanted to quit.¹² Furthermore, a nationally-representative, observational study of YAs who tried to quit smoking reported no difference in success between YAs who used ENDS, NRT, and unassisted attempts.¹³

These mixed findings raise questions about why ENDS have helped some individuals quit smoking but not others, and how YAs actually use ENDS for smoking cessation in real world, outside of clinical trials or laboratory conditions. The complexity of dual use behavior, facilitated by the variety of ENDS devices and individual use patterns of both tobacco products, is hard to capture in quantitative measures.¹⁴ Qualitative inquiry, which elaborates on participants’ experience, can complement quantitative measures by providing insight into the array of experiences of using ENDS in smoking cessation attempts.^15–17

We conducted a longitudinal qualitative study in a cohort of YAs reporting dual tobacco use during 2017–2019. This approach provided detailed information on changes in YA attitudes, motives, and real-world experience of tobacco/nicotine use over two years of their life, allowing for both within-person and between-person comparisons.¹⁸ Our research questions were: What are YAs’ lived experiences with using ENDS to quit smoking? and Why are YAs successful or unsuccessful in replacing cigarettes with ENDS?

METHODS

Design and participants

This study considered a subset of 60 YAs from a longitudinal qualitative study of dual tobacco/nicotine product use.¹⁹ Participants were recruited online and were sampled purposively to ensure diverse tobacco use patterns. Eligible participants at baseline were 18–29 years old, residing in California, and using at least two of three products (cigarette, ENDS, smokeless tobacco). They were invited to participate in in-depth interviews in 2017 (Wave 1), 2018 (Wave 2), and 2019 (Wave 3). Participants provided informed consent and received a gift card for participation at each wave. While the inclusion criteria did not include intention to quit smoking, many participants reported using ENDS to quit/reduce cigarettes at baseline, making it worthy of further investigation. The longitudinal qualitative approach allowed us to follow up with these participants to elicit their experience with cessation. This analysis included 25 participants (75 interviews) who completed all three waves and explicitly stated that they used ENDS to reduce/quit smoking. Online supplemental table 1 displays the sample’s baseline characteristics (e.g., mean age of 23.6 years old; 24% female; 32% non-Hispanic White).

Data collection

Trained interviewers with various experience in tobacco control research conducted in-person and phone interviews. Each interview lasted 60–90 minutes. Before each interview, participants reported their demographics and number of days they used each tobacco product in an online survey. We developed interview guides based on the literature about YA tobacco use.¹² Key domains included daily tobacco use routines, motivations and context for use, and perceived harms and benefits related to use (online supplemental table 2). Interviews conducted at Waves 2 and 3 covered these domains with individually tailored questions based on participants’ previous responses. Interviewers wrote a field note for each interview, including context information, a summary of the interview, and notes on the interview quality.²⁰

Data analysis

All interviews were audio-recorded, transcribed verbatim, and reviewed for accuracy. Transcripts were uploaded into Dedoose, a qualitative data analysis platform.²¹ Our team collaboratively derived an initial set of deductive codes based on the interview guides; new codes emerged during in-depth reading of the transcripts as we identified concepts, ideas, and experiences that appeared frequently across participants. We used thematic and trajectory analysis methods to compare changes in tobacco use for each participant and between participants over time.^18,22 First, we reviewed field notes to summarize key changes in each participant’s tobacco use. We then created a data matrix for each participant to visualize the trajectories over time (online supplemental table 3). We grouped cases with a similar trajectory together and analyzed shared features within each trajectory group. Our team critically discussed each case to ensure our interpretations were credible and confirmable. Finally, we compared narratives across two subgroups: participants who successfully replaced cigarettes with ENDS and those who did not. Making both within- and between-person comparisons, our team reviewed full transcripts, extracted data, iteratively compared narratives across participants to identify prominent themes and sub-themes, and selected representative quotations. The first and second authors summarized the themes, and the other authors reviewed the findings to ensure that they reflected their understanding of the data. We reported results based on the Standards for Reporting Qualitative Research guideline.²³

RESULTS

Young adults’ tobacco use transitions

Participants reported various changes in tobacco use over the two-year study period. Most (21 out of 25 participants) maintained their initial dual use and 4 participants transitioned to exclusive ENDS use at Wave 2 (Figure 1). By Wave 3, five main transitions were: Sustained dual use without reduced smoking (8 participants maintained, or even increased, their smoking days and were still using ENDS); Transition to exclusive daily ENDS use (6 participants completely quit smoking and were using ENDS daily); Sustained dual use with reduced smoking (5 participants reduced their smoking frequency from 15–30 days to 1–3 days/month and were still using ENDS); Transition back to exclusive smoking (4 participants still smoked cigarettes and stopped using ENDS); and Transition to neither smoking nor ENDS use (2 participants reported quitting smoking and almost no ENDS use, with one reporting an occasional vaping. Both participants had the same transition over time, moving from dual use at wave 1 to exclusive ENDS use at wave 2, and finally to no tobacco use at wave 3).

Figure 1:

Tobacco use transitions over the 2-year period (2017–2019) among young adults (n=25) who used electronic cigarettes to try to reduce or quit smoking cigarettes. Different dashed and solid lines indicate different tobacco use patterns. ENDS, electronic nicotine delivery systems.

Young adults’ ENDS use experience for smoking cessation/reduction purposes

Regardless of whether they succeeded in quitting/reducing smoking, YAs commonly reported “chain vaping” (continuously using ENDS without a break), manipulating nicotine concentrations, and switching between different devices and flavors in their ENDS use routine (Table 1).

Table 1:

Summary of themes on young adults’ experience of using e-cigarettes for quitting/reducing smoking cigarettes

Main themes	Description and exemplary quotes
Real-world experience with using e-cigarettes during smoking quit attempts
Chain vaping	No endpoint for ENDS use sessions and convenience and ease of using ENDS indoor or anywhere resulted in continuously using ENDS without a break. The chain vaping may increase in nicotine consumption.
Manipulating nicotine concentrations	Changing or varying nicotine concentrations in different ENDS device and using high nicotine levels to get more nicotine satisfaction or to smoke less cigarettes.
Switching between different devices and flavors	Switching devices and flavors to get nicotine satisfaction, address adverse experiences (e.g., poor device performance, bad taste, high costs), and fit specific vaping contexts.
Reasons for successful replacing cigarettes with e-cigarettes
Perceived positive physical effects	Perceiving physical changes that they interpreted as health improvement (e.g., less coughing, easier breathing, better exercise performance) when switching from cigarettes to ENDS.
Perceived satisfaction and enjoyment of ENDS use	Perceiving similar nicotine satisfaction and more pleasure (e.g., no smell, convenience for use at workplace and traveling) from ENDS than cigarettes.
Context changes	Smoking-related triggers (e.g., hanging out with friends, drinking alcohol, or around other smokers and/or drinkers) disappeared or reduced, and thus, discouraged smoking cigarettes.
Reasons for unsuccessful replacing cigarettes with e-cigarettes
Perceived negative physical discomforts of ENDS use	Experiencing physical discomfort from e-cigarette use (e.g., difficulty breathing, dry mouth, headache).
Perceived addictiveness and harm of ENDS use	Expressing concern about addiction to ENDS due to chain vaping (e.g., they were able to vape more than they had smoked), high nicotine concentration in e-liquids, and unsafe chemicals in e-liquids.
Unsatisfactory substitution for cigarettes	Feeling insufficient nicotine sensation or physiological effects from ENDS compared to cigarettes (e.g., insufficient throat hit or head rush), and perceiving that cigarettes were better to cope with stress than ENDS.
Device malfunction	E-cigarette devices kept leaking or breaking and cost for maintenance and replacement was high.

Chain vaping:

Many participants stated that they could control their nicotine consumption from cigarettes by tracking number of cigarettes smoked (“a fixed amount of nicotine”) and could easily define the end point of smoking – when a whole cigarette was burnt. However, when vaping, the endpoint was less clear and must be self-imposed. Such difficulty resulted in intense use throughout the day without realizing how much nicotine they consumed, as stated by Participant ID16 (26-year-old male): “For a cigarette, it’s timed, it ends at some point. And, vaping you can just keep picking it up.” Participant ID22 (19-year-old female) believed chain vaping increased her nicotine consumption: “I would chain vape for a half hour and then be good for two hours and then chain vape again. I would say that I vaped more than I actually smoked cigarettes.” That ENDS could be used more freely and easily than cigarettes (e.g., Participant ID16 - “when you’re bored [indoors] or stuck in traffic”) also facilitated chain vaping.

Manipulating nicotine concentrations:

Participants reported changing or varying nicotine concentrations in their ENDS to yield satisfactory ‘hits’. Participant ID16 (26-year-old male) used 6 mg nicotine liquid in his box mod and 26 mg nicotine liquid in his pod vape because “you actually have to add a bunch of nicotine because it [pod vape] burns way lower. You have to bump it all the way up to 26 milligrams of nicotine to get the same hit or feel that you get [from the box mod].” To get the same nicotine satisfaction as they got from cigarettes, some participants used a very high nicotine concentration (e.g., 60mg), “I like going for more potent ones because I can get pretty much the same effect with fewer drags. It basically feels most like a cigarette than anything else” (Participant ID04, 26-year-old male). Participant ID24 (27-year-old female) attributed her reduced smoking to such change: “When I moved nicotine concentration up from 3mg to 12 mg, I started smoking less cigarettes.”

Switching between different devices and flavors:

Participants switched devices and flavors to get nicotine satisfaction, address adverse experiences (e.g., poor device performance, bad taste, high costs), and fit specific vaping contexts. Those who switched from JUUL to other ENDS often described having a headache from using JUUL: “Something about JUUL was giving me a headache. So, I kind of weaned off that and got one of the generic pens” (Participant ID01, 28-year-old male). Several participants preferred mod vapes over vape pens since the mods were sturdier, had longer battery life, better flavor production, and could be used with a greater variety of e-liquids. Some participants owned both large and small devices to facilitate vaping in different contexts: “If I’m going to a friend’s house, I’ll take the big one. But where I’m not gonna be able to place it somewhere safely, I just take the small one ‘cause it fits in the pocket” (Participant ID16, 26-year-old male). This participant also referenced new terminology to indicate altered or decreased flavor taste over time, further demonstrating how participants manipulated specific features of their devices to facilitate use: “I have heard it coined as vapenesia, where if you smoke the same flavor for far too long, you don’t taste it anymore. So, I always change it every two tanks. It’s like once a month I’ll change flavor.”

Reasons for successfully replacing cigarettes with ENDS

Of the 13 participants who reduced/quit smoking by using ENDS, common reasons for the successful replacement were perceived positive physical effects, perceived satisfaction and enjoyment of ENDS, and changes in context that reduced smoking cues (Table 1).

Perceived positive physical effects:

Participants perceived physical changes that they interpreted as health improvement (e.g., less coughing, easier breathing, better exercise performance) when switching from cigarettes to ENDS. These perceived health improvements supported their commitments to avoid smoking and continue using ENDS. Participant ID01 (28-year-old male) described: “Comparatively to cigarettes, I would wake up feeling a lot less like crap. After a day of smoking cigarettes, definitely the next morning I wake up and I just feel like there’s a weight in my chest. My mouth would feel drier, my hands and everything smells like tobacco; it’s disgusting. But using a vape pen or a JUUL pod, my mouth would be a little dry. So, you feel healthier.” These reports contrast to participants whose perceived negative health effects from ENDS served as a barrier to replacing cigarettes with ENDS.

Perceived satisfaction and enjoyment of ENDS:

Those who successfully replaced cigarettes with ENDS perceived similar nicotine satisfaction and more pleasure from ENDS than cigarettes. Participant ID16 (26-year-old male) described JUUL as “a cigarette replacement” making him feeling “really lightheaded as from smoking Newport or American Spirit Blacks.” These participants did not miss smoking and even described cigarettes as “disgusting” after they switched to ENDS. Participant ID14 (24-year-old male) said: “I used to smoke cigarettes and never realized how gross it felt. Like, you just feel it in your saliva, and your hands and face smell, your clothes smell. I don’t know if I can ever go back to this.” Their enjoyment was associated with perceived benefits of ENDS, such as easy and quick access to nicotine while traveling or at work:

“If you’re in an elevator or a place that you can’t leave and you need a nicotine really quick, it is so much easier… I just need to calm down for a second; I can just go in the bathroom. ‘all right, cool, let’s get back to work.’ So yeah, I enjoyed that part”

(Participant ID01, 28-year-old male).

Context changes:

Participants often smoked cigarettes in social contexts (e.g., hanging out with friends, drinking alcohol, or being around other smokers and/or drinkers). When these contextual triggers happened less frequently or disappeared, so did their smoking. Some participants reported that their tobacco use gradually went down as they and their friends became more mature. Participant ID13 (24-year-old female) described her new friends as “more responsible and a lot healthier than my old group of friends. So, I guess it motivated me to become a better person.” Likewise, starting new jobs, moving to new locations, or living with non-smoking partner/roommates deterred participants from smoking. A medical student (Participant ID02, 23-year-old male) stopped smoking due to smoking-related stigma among medical professionals: “I could never smoke in medical school. Because the social stigma behind it is humongous.”

Reasons for unsuccessfully replacing cigarettes with ENDS

There were 12 participants who could not reduce cigarette smoking after using ENDS. Common reasons for this unsuccessful replacement were perceived negative physical discomforts, perceived addictiveness and harm of ENDS, unsatisfactory substitution for cigarettes, and device malfunction. Increased perceptions of negative consequences of ENDS discouraged them from using ENDS (Table 1).

Perceived negative physical discomforts:

Common symptoms participants experienced from using ENDS were dry mouth, headache, and lung irritation. Participant ID11 (20-year-old male) mentioned: “I used to get lung irritation. It would feel really painful. It [vaping] was bothering me, making me sick. Might just stick to cigarettes, even though it’s not necessarily a healthier alternative. It hasn’t given me the negative effects, so I transitioned [back to smoking].” Participant ID20 (18-year-old male) described:

“Another big reason why I quit JUUL was it would suppress my appetite. It would make my heart rate go up. I could feel my chest get short of breath. There’s sometimes you hit the JUUL and it goes down wrong, and you cough. Coughing on JUUL is worse than coughing on a cigarette.”

Perceived addictiveness and harm of ENDS:

Some participants expressed concern about addiction to ENDS due to chain vaping (e.g., they vaped more than they had smoked) and high nicotine concentration in e-liquids. Participant ID09 (25-year-old male) went back to smoking because of this: “We looked it up online and we found out that they [the VUSE] actually had way more nicotine than regular cigarettes would sort of make them very addictive. I kind of freaked out and started smoking cigarettes again.” Participant ID11 (20-year-old male) was concerned about glycerin in e-liquids: “Even though they say it’s [ENDS] like a healthier alternative, I don’t think it’s healthier since it’s glycerin heated up. If that’s heated up and making a vapor, that’s not necessarily fully water vapor. So, I thought there would be a negative effect to that.”

Unsatisfactory substitution for cigarettes:

Many participants described not feeling sufficient nicotine sensation or physiological effects from ENDS compared to cigarettes (e.g., insufficient throat hit or head rush). Participant ID09 (25-year-old male) said: “I’m doing both, I’m smoking and vaping. It’s hard for ENDS to really compete with regular cigarettes because cigarettes hit you so much harder. So, sometimes I just want that [cigarette] instead, which also makes it difficult [to quit].” Participant ID22 (19-year-old female) also thought that ENDS were not as strong as cigarettes, which deterred complete switching: “I don’t really like them [ENDS] because they’re airy… If they were stronger and more tobacco-y, I would probably smoke them.” Furthermore, participants explained how stress contributed to smoking relapse since cigarettes were perceived as “a security blanket” that helped them cope with stressors better than ENDS. Participant ID12 (28-year-old female) explained:

“About six months ago, I wanted to quit [cigarettes], so I transitioned to those [ENDS], and I was actually able to go cigarette-free for three or four months. But then, I got promoted at work, and stress, and I was like on autopilot. I went and bought a pack of cigarettes. In the end, I ended up coming back to cigarettes.”

Device malfunction:

Some participants stopped using ENDS due to the fragility of the device (e.g., device leaking or breaking, high maintenance requirements) and related costs. They thought that maintaining ENDS devices was a huge hassle. Participant ID22 (19-year-old female) relapsed to smoking due to this reason:

“I had my vape pen, which is just like a SMOK stick. It has a glass chamber, and I kept breaking it continuously. I was working overnight shifts at the time. So, when I would break it, I didn’t have any backups. So, I eventually just went out and got a pack [of cigarettes].”

DISCUSSION

Using longitudinal qualitative data, this study provides a nuanced understanding of YA tobacco use transitions over time and elucidates real-world experiences with using ENDS as a smoking cessation aid. In our sample of baseline dual tobacco users, two participants quit both smoking and vaping, some transitioned to exclusive vaping, some relapsed to exclusive smoking, and most maintained dual use. These transitions were similar to those in a longitudinal qualitative study of UK smokers (e.g., exclusive e-cigarette use, neither smoking nor using e-cigarettes, and sustained dual use or back to exclusive smoking).¹⁷ Our study had a longer follow-up period (2017–2019 vs. 2017–2018) in a younger sample (mean age of 23.6 years old vs 42). Despite differences in these study characteristics and tobacco control policy context, our study shares common reasons for successfully (e.g., perceived health benefits, pleasure, and satisfaction from ENDS) and unsuccessfully quitting smoking with ENDS (e.g., unsatisfied by ENDS, physiological intolerance, concerns about health risks of ENDS). To our knowledge, our study is the first longitudinal qualitative study illuminating the complexity of ENDS use patterns among US YAs with detailed information on changes in devices, nicotine concentrations, flavored e-liquids, and vaping quantity during smoking quit attempts.

The longitudinal data allowed us to capture changes in perceptions of ENDS that appeared to drive YA smoking behaviors. At baseline, all participants reported using ENDS at least in part for smoking reduction/cessation. Experience using ENDS over time changed their perceptions, particularly perceptions related to addiction and nicotine delivery, positive or negative physical sensations, and social contexts. Those who could replace cigarettes with ENDS perceived more benefits (e.g., convenience for indoor use, positive physical effects) from ENDS than from cigarettes. Conversely, those who did not fully switch to ENDS perceived greater drawbacks from ENDS (e.g., increased addictiveness, maintenance costs).

One common support in smoking cessation counseling is to anticipate and plan for physical and mental discomforts associated with quitting. Our participants did not utilize behavioral counseling and may have been more likely to give up using ENDS or revert to smoking when experiencing discomforts as a result. Published randomized trials that report efficacy of ENDS for smoking cessation provided counseling, whereas observational studies of ENDS (typically decoupled from counseling) showed no benefit.¹⁰ Our findings suggest that ENDS for smoking cessation should be linked to behavioral counseling to support efficacy.

Our participants experienced multiple physical sensations they interpreted as positive and negative health effects related to ENDS use. While some participants reported perceived improvement in breathing and exercising by replacing cigarettes with ENDS, others complained about dry mouth, headache, lung irritation, increased heart rate, and appetite change. Due to the variation of participants’ use practices in terms of e-liquids, device types, and vaping quantity, we could not identify which specific factors contributed to these physical effects. While adverse effects probably warrant discontinuing use of ENDS products, engagement with behavioral counseling might discourage reversion to smoking or encourage NRT as an alternative for those who find ENDS ineffective.

Our findings are similar to another qualitative study which showed that ENDS’ customizability facilitated the smoking cessation process among both young and older adults.²⁴ Heterogeneity in product use may also partly explain the mixed findings on the effectiveness of ENDS for smoking cessation in observational studies, which cannot standardize devices and nicotine concentrations.¹⁰ Our participants also expressed difficulties quantifying how much nicotine they were using, particularly with chain vaping or when using multiple devices. Although prior research suggested that ENDS should be used daily to support smoking cessation,^9,10 the chain vaping phenomenon observed in this and other studies⁷ raises concerns about potential nicotine addiction and unknown harms of long-term ENDS use. Unquantifiable intake also makes it difficult to plan nicotine dose reduction with ENDS as one might do with NRT. Standardized ENDS products and provision of information about nicotine doses may facilitate users’ ability to select an appropriate product for nicotine replacement and to plan reduction over time.^25–28

Our results have important implications for research, practice, and policy. ENDS have been marketed as a smoking cessation aid²⁹ without endorsement by most US health authorities.³⁰ In the absence of official endorsement and without specific guidelines on how ENDS can be used to successfully quit smoking, YAs are left to experiment and self-titrate with often frustrating, expensive, risky, and/or unsuccessful results. To make dual use a temporary state on a pathway to complete nicotine cessation rather than a sustained alternative to nicotine consumption, future studies should characterize which nicotine levels, how frequent, and how long ENDS should be used to enhance smoking cessation. Consistent with previous work,^10,31,32 we suggest that guidance on ENDS use for smoking cessation should be developed as with prescribed NRTs, with instruction on specific devices, nicotine concentrations, times used per day, and use duration. Regulation on ENDS product standards should take into account both characteristics of e-liquids (e.g., maximum threshold of nicotine concentration, other ingredients) and devices (e.g., power).^25–28 In addition, the high variability and limited smoking cessation efficacy of YAs’ ENDS use without behavioral support suggest that YAs may find tailored advice and counseling to be helpful. Integrating mental health supports in tobacco cessation interventions may also be beneficial to YAs since stress was a common driver of smoking relapse in our study and previous research.^17,33 Finally, young adulthood is a dynamic life stage with unique transitions in residence, employment, education, and relationships. These transitions contributed to changes in tobacco use, as we found that YAs reduced or quit smoking when their life contexts changed (e.g., starting medical school, moving in with non-smoking partner). This suggests that tobacco interventions for YAs may be tailored to leverage contextual changes (e.g., encouraging healthier lifestyle adoption during a life transition, providing timely social and peer supports) to promote and maintain abstinence among YAs.

Our study has several limitations due to the nature of qualitative research with a sample recruited in California, a state with a strong tobacco regulatory environment. Findings may be different in other policy contexts. Our sample with a high proportion of males may impact the findings since there are sex differences in tobacco use and successful cessation.³⁴ The generalizability of our findings may be limited by the inclusion criteria that required participants to use at least two tobacco products; however, using multiple tobacco products is common among YAs, alleviating such concern.⁴ Participants’ narratives of tobacco use may be subject to social desirability bias and participants might have hesitated to disclose failed quit attempts.

CONCLUSIONS

This longitudinal qualitative study documented a spectrum of YAs’ lived experiences with using ENDS for smoking cessation, illuminating how and why most YAs continued to use ENDS and cigarettes at least two years after intending to use ENDS to quit smoking. Participants who quit smoking were more likely to perceive positive health effects and nicotine satisfaction from ENDS, while those who resumed or continued smoking were more likely to experience adverse symptoms from ENDS. Some participants perceived ENDS as more addictive than cigarettes, while others perceived ENDS did not deliver nicotine satisfaction; both reasons discontinue ENDS use. Results suggest that providing behavioral counseling and standardising ENDS products may enhance the success of using ENDS for smoking cessation among YAs.

What is already known on this topic

Young adults often use electronic nicotine delivery systems (ENDS) during attempts to quit smoking cigarettes. Little is known about their lived experience of using ENDS for smoking cessation in the real world.

What this study adds

In the absence of guidelines on how ENDS can be used for smoking cessation, young adults are left to self-titrate with a variety of vaping quantities, nicotine concentrations, flavors and devices, yielding frustrating, expensive, risky, and/or unsuccessful results.

How this study might affect research, practice or policy

Results suggest that providing behavioral counseling and standardising ENDS products with optimal nicotine delivery may enhance the success of using ENDS for smoking cessation among young adults.

Data availability statement:

The qualitative data underlying this article, even deidentified, may include some information that can sufficiently specify the participant, therefore cannot be shared outside the research team. The quantitative data including tobacco use and socio-demographic characteristics will be shared on reasonable request to the corresponding author.