Uncontrolled vaping and restraint strategies: A qualitative study

Abstract

Introduction.

Little is known about uncontrolled vaping, defined as vaping more than the user prefers. We sought to understand e-cigarette users’ experiences with uncontrolled vaping and how they restrain their vaping.

Methods.

Participants were 24 US adult e-cigarette users recruited in 2021. We conducted semi-structured qualitative interviews about uncontrolled vaping and restraint strategies and analyzed findings based on behavioral categories described in the Process Model of Self-Control.

Results.

While most participants (21 of 24) described experiences of uncontrolled vaping, some expressed ambivalence about how much they vaped. To restrain vaping, willpower was rarely used and was not perceived as effective. Distraction, deployment of attention away from the urge to vape, and reappraisal, thinking differently about vaping such as reminding oneself of health consequences, were common and helped some participants limit use in the moment of wanting to vape. Participants described using both situation selection, choosing to be in situations where e-cigarette use was less possible, and situation modification, modifying their circumstances to restrict opportunities to vape.

Discussion.

Uncontrolled vaping is not yet a well-defined concept for many e-cigarette users. E-cigarette users employed proactive situational strategies that required planning ahead to restrain use and found these strategies more effective compared to reactive strategies. Tobacco control programs and interventions should consider leveraging restraint strategies that people who vape are naturally using and perceive to be effective.

INTRODUCTION

E-cigarette use, or vaping, is common in the United States (US). In 2021, 4.5% (estimated 11.1 million) US adults reported using e-cigarettes some days or every day.¹ Use increased from 3.7% in 2020, which was driven by high prevalence (11%) among young adults aged 18–24 reporting current e-cigarette use in 2021.¹ Also, in 2023, approximately 2 million youth reported e-cigarette use in the past 30 days.² An estimated 2.2% of US adults use both combustible cigarettes and e-cigarettes.³

High rates of vaping have drawn concern over e-cigarette dependence.^4,5 Researchers have responded by identifying indicators of dependence specific to e-cigarettes^6–8 and developing measures of e-cigarette dependence⁹ building off traditional measures of combustible cigarette-induced nicotine dependence.^10–12

In addition to dependence, some users experience uncontrolled vaping, defined as vaping more than the user prefers (i.e., in greater quantity or duration). Because vaping can be difficult to measure, uncontrolled vaping could include more puffs, vaping sessions, or time spent vaping than the user prefers. This phenomenon has been briefly described in qualitative research and news reports yet remains unstudied.^13,14 Characteristics of e-cigarettes that make vaping appealing such as sweet flavors,¹⁵ a sense of community with others who use e-cigarettes,¹⁶ social acceptability in a broad range of settings,¹⁷ and lack of familiar stopping cues may make uncontrolled use harder to avoid. While believed to be less harmful than combustible cigarettes, e-cigarettes still have some risks, and uncontrolled use could put users at higher risk of e-cigarette-related health issues including respiratory and cardiovascular complications.^18,19 E-cigarette users may be able to manage uncontrolled vaping through restraint strategies, as self-regulation can occur at multiple points during impulse generation.^20,21 While a robust literature has documented restraint in the context of alcohol, diet, and smoking, evidence on restraint strategies to control e-cigarette use lags behind.^22–24

To better understand uncontrolled vaping and restraint, we looked to the Process Model of Self-Control (Process Model) that asserts impulse generation occurs as an iterative cycle starting with a situation, followed by attention, an appraisal, and finally a response that guides the individual to a new situation.²¹ Self-control strategies can occur at any stage of this cycle, and these strategies can be grouped into 5 categories. Early in this cycle and well before experiencing acute e-cigarette cravings, an individual can choose situations that support their goal and reduce temptation (situation selection). Similarly, situation modification entails a change to an existing situation to reduce temptation. If the situation itself cannot be changed, an individual can use three additional strategies to support self-control. Reappraisal involves an individual viewing a situation in a new light, often through thinking about a future self or a high-level cause for an action. Distraction is about the deployment of attention and involves redirecting attention away from the relevant stimulus or situation. Lastly, one could intentionally suppress undesired impulses via willpower. While the Process Model of Self Control has been applied previously in tobacco research,^25,26 we expand the prior use of the model to this new context of vaping restraint.

Building on the Process Model of Self Control, we sought to identify new opportunities for tobacco control related to vaping restraint. Specifically, this study aimed to (1) identify strategies that e-cigarette users deploy to restrain their vaping behavior, (2) map restraint strategies onto the Process Model, and (3) characterize perceived efficacy of restraint strategies.

METHODS

Participants

In early 2021, we recruited 24 US adults who were current e-cigarette users, using the CDC definition for current use which is vaping every day or some days at the time of the survey.¹ We selected this sample size because we have found that this number of participants is typically sufficient to reach saturation in qualitative studies, in line with prior research.^27,28 We identified participants through targeted ads on Facebook and Craigslist. We prioritized the inclusion of participants who reported limiting their vaping in some way. A screener survey assessed eligibility based on demographic information, vaping behavior, and whether they ever limited or controlled their vaping. Respondents were eligible if they were 18 years or older, currently used an e-cigarette with nicotine, able to read and speak English, and able to complete a video interview over Zoom with audio recorded. The screener gathered data on ethnicity, use patterns, and device characteristics enabling us to purposively sample participants for diversity across these factors. To measure device characteristics, participants reported whether the e-cigarette they used most frequently (1) required a cartridge or pod, (2) contained a tank system, and (3) was disposable. We categorized participants ages 18–25 years as young adults (YA) and ages 26 years or older as adults.

Procedures

Research staff conducted interviews via live video calls. Two participants requested audio-only calls due to their preferences about privacy or limiting cellular data use. Participants provided verbal informed consent at the beginning of the interviews. Interviews ranged from 22 minutes to 48 minutes long, with a median length of 28 minutes. At the end of the interview, participants received information about the harms of tobacco use and resources for quitting. Participants received $40 gift cards for completing the interview. This study was approved by the Institutional Review Board of the University of North Carolina (#19-3507).

Measures

Research staff used a semi-structured interview guide to ask about general e-cigarette use behavior including how and when participants used e-cigarettes and their e-cigarette use from the day before the interview, probing for details such as how many different times they vaped, where they vaped, and how it compared to their typical use. The interviewer then asked questions about uncontrolled use, such as, What would be the ideal amount of vaping for you in a typical day? And Sometimes people find themselves vaping more than they mean to. Tell me about any experience you’ve had with this. Next, research staff asked participants to share about a time they tried to keep themselves from vaping too much and then probed for specific strategies to control vaping such as decisions or rules about when, where, or with whom they use e-cigarettes; keeping track of how much they vape; avoiding situations that make vaping easy; doing things that make it harder to vape; and penalizing or rewarding themselves depending on restraint success. Interviewers also asked what kinds of things participants would think or tell themselves when trying to avoid or limit e-cigarette use to understand cognitive strategies and asked how well the strategies they endorsed typically worked for controlling use. These types of strategies were selected to cover all 5 categories in the Process Model. If participants reported family or friends who also vaped, we asked about things their family or friends had tried to keep themselves from vaping too much and probed for reactions to their networks’ restraint strategies.

More examples and definitions of strategies appear in Table 1. Three members of the research team (CW, THB, SAD) led interviews using video conferencing. Interviews were also recorded and transcribed on Zoom. Automatic transcriptions were manually corrected before coding. After each researcher had conducted their first interview, the research team met to refine the interview guide and used the revised version to conduct the remainder of interviews.

Table 1.

Definitions of Process Model restraint strategies²¹

Term	Definition	Example	Number of participants endorsing strategy
Willpower	Use of individual motivation, or determination, to control how much to vape, suppressing the urge	Participant uses self-control to not vape in a specific situation	12
Reappraisal	Trying to think differently about vaping, in the moment	Reminding oneself of the negative health consequences of vaping when the craving strikes	16
Distraction	Thinking of something other than vaping or doing something to distract from vaping, in the moment	Participant plays a game with his child to refocus his attention when he feels the urge to vape.	17
Situation Modification	Changing a situation, either ahead of time or in the moment, to make vaping less tempting or accessible, including implementing awards or penalties	Participant gives their e-cigarette to someone else to make it more difficult to vape	19
Situation Selection	Choosing situations that will reduce urges to vape	Participant decides to stay home from the bar because drinking alcohol makes them want to vape	9

Data Analysis

Researchers coded interviews using Dedoose software.²⁹ We used qualitative content analysis³⁰ and thematic analysis^31,32 to identify recurring themes around experiences of uncontrolled vaping and use of restraint strategies. We started with deductive thematic codes that were general vaping behaviors, uncontrolled use, and the 5 restraint strategy categories from the Process Model. We then added inductive thematic codes after the first three interviews and continued to refine codes as needed. For codes that were added later in the process, we reviewed previously coded transcripts and applied newer codes where appropriate. Operational definitions and examples for the codes appear in Table 2. Each interviewer coded their own interviews before a second interviewer independently coded each interview. The two coders discussed and reached consensus on codes for each interview. We applied only one code to each strategy that participants mentioned. Finally, we exported coded excerpts from Dedoose for analysis. Staff added pseudonyms after analysis to contextualize the breadth and source of quotations while protecting privacy.

Table 2.

Demographic and e-cigarette use characteristics (n=24)

Characteristic	n (%)
Age, years  18–25 (young adults)  26+ (adults) Mean Age (SD), years	9 (38) 15 (62) 32 (10.5)
Gender  Female  Male	13 (54) 11 (46)
Race  White  Black  More than one race	12 (50) 10 (42) 2 (8)
Education  High school/GED  Some college or technical school  Bachelor’s degree  Graduate degree	4 (17) 9 (37) 10 (42) 1 (4)
E-cigarette device characteristics  Disposable  Tank system/mod  Cartridge/pod	11 (46) 13 (42) 17 (71)
Limited or controlled vaping  No  Yes	8 (33) 16 (67)
Cigarette use  Dual use of vapes and cigarettes  E-cigarette use only, previously smoked  E-cigarette use only, never smoked	11 (46) 6 (25) 7 (29)

Notes. No participants identified their gender as non-binary or other category.

E-cigarette device characteristics are non-exclusive.

GED = General Educational Development certification.

RESULTS

Participants’ ages ranged from 18 to 56 years (M = 32). At the time of the study, 11 participants reported dual use (46%), 6 used e-cigarettes only but previously smoked (25%), and 7 used e-cigarettes only and never smoked (29%). We prioritized inclusion of those who reported limiting or controlling their vaping (67% of the sample). Participants predominately used e-cigarettes that were disposable (46%), had tank systems (42%), and used cartridges or pods (71%).

Uncontrolled Use

Most participants recalled experiencing uncontrolled vaping (21 of 24 participants). For some, it was as simple as noticing that they are vaping “too much”:

From the time I get up, I’m always looking for it, so every day is really too much. Just because when I have to go back to work, I won’t be able to have it at my desk, so every day is too much. [Emily, adult, e-cigarette use only, previously smoked]

Many participants expressed apparently contradictory ideas or mixed feelings about their vaping throughout their interviews. For example, some stated that they vape about the right amount but later mentioned wanting to eventually reduce their vaping. This was especially true among current or former cigarette smokers. This was due in part to perceived benefits of vaping compared to the negative consequences of smoking:

Because of having quit smoking cigarettes, it feels like a much, sort of, better alternative. I don’t feel as horrible. So, for now, it feels like a win, all the way around. But ideally it’s more than what I would be doing in the future. [Ella, adult, e-cigarette use only, previously smoked].

Some participants also reported mindless vaping—vaping without consciously intending to do so:

No [vaping is] just kind of like a habit it’s-- I’m not even aware that I’m doing it a lot of times [Fatima, adult, dual use]

Mindless vaping may contribute to uncontrolled vaping if a user finds themself reflexively using e-cigarettes when they prefer not to vape.

Comparison of Vaping and Smoking

Participants often compared vaping and cigarette smoking. The interaction between e-cigarette characteristics and environmental context influenced decisions about whether to vape or smoke. For example, compared to smoking, participants were more open to vaping in their cars, around other people, and inside buildings. Vaping was popular for its pleasant scents and discreet nature in public contexts.

You can vape anywhere, not anywhere, but next to a person and there’s no smell. In fact, it has a good aroma. And you can kiss somebody and there’s no taste. [Kathy, adult, e-cigarette use only, previously smoked]

Participants were quick to note difficulty quantifying e-cigarette use compared to cigarettes, since cigarettes can easily be counted while e-cigarettes lack discrete stopping cues like reaching the end of a cigarette. Instead, participants estimated their typical number of e-cigarette puffs per day, ranging from 0 (participant had recently started a quit attempt) to 250. Many followed their estimates with comments expressing uncertainty, explaining it was difficult to know how much they vaped. One other key difference between vaping and smoking is that participants viewed vaping as less dangerous and more socially acceptable than cigarettes. They also believed people they know agreed that vaping is less harmful than smoking:

They don’t have a problem with it. They prefer me vaping over smoking actual cigarettes. [Tim, adult, dual use]

Participants’ social networks often viewed the harms of e-cigarette use comparatively against combustible cigarettes and expressed general acceptance of their loved one’s vaping. Several participants brought up having used, or wanting to use, e-cigarettes to help stop smoking combustible cigarettes. Of those who had successfully quit smoking, some wanted to also quit e-cigarettes.

Restraint Strategies and Process Model Categories

Participants described employing a variety of strategies to attempt restraint, summarized below following the categories of the Process Model.

Willpower.

About half of participants described using willpower as a strategy, but it rarely worked to limit vaping. Sarah [YA, e-cigarette use only, never smoked] described her friend’s use of willpower to create rules around when to vape, saying “I think [willpower] worked in the beginning, but I feel like now she just kind of doesn’t care.” A participant talked about how trying to quit cold turkey didn’t last:

...I kind of kicked it for like a week, because I noticed that I started doing it sober. I just stopped and said I wasn’t going to vape. But then it came back up after a week of kicking it. [Sebastian, YA, e-cigarette use only, never smoked]

Determination to quit vaping was seen as an important first step to behavior change, but willpower alone was not enough to carry participants through the challenges of quitting e-cigarettes.

Reappraisal.

Of the participants who described using reappraisal, many considered the negative health consequences that result from vaping (12 of 16 participants).

And the only thing that really bothers me is that I know that it’s not healthy and so that’s like the only thought I can really hold on to help encourage myself not to [vape]. [Hannah, adult, e-cigarette use only, previously smoked]

A few were concerned about lack of knowledge of long-term effects of e-cigarettes. Sebastian said,

I know that we don’t really know about health side effects of vaping now, so it’s almost like just try to make myself feel bad about it. Like “look it’s not worth your time, it’s not worth anything.” [YA, e-cigarette use only, never smoked]

Instead of thinking about enjoyable aspects of vaping, these participants reminded themselves of the potential risks of vaping to make using e-cigarettes less appealing.

Distraction.

Over half of participants described distraction to limit their vaping. Once aware of the impulse to vape, participants mentioned staying busy through exercise, daily tasks and chores, connecting with others, or other tasks that shifted their attention away from vaping:

I try to keep myself busy. Maybe go for a walk or go to a park and that way, as long as you’re busy then you’re not getting so much downtime so you’re not vaping as much. [Jayden, adult, dual use]

Another common theme among those who reported using distraction strategies was oral distraction—chewing gum, eating, or biting fingernails instead of using e-cigarettes. One participant said,

I don’t feel like anything else would work, except like eating or chewing gum because it’s just something to do with my mouth, and I’m not thinking about vaping. [Hannah, adult, dual use]

While examples of distraction sometimes included additional situational changes, the element of shifting mental attention away from an active craving makes these distinct from purely situational strategies.

Situation Modification.

Nearly all participants talked about situation modification as a way of limiting vaping. Participants described a wide range of situation modifications. The most common form was temporarily limiting access to the e-cigarette.

If I find myself overly stressed, and I know that it’s going to be me constantly hitting the vape pen, I will oftentimes you know take a few hits and then I’ll put it in another room so it’s not readily available to me. [Ava, adult, e-cigarette use only, previously smoked]

Limiting access to the e-cigarettes had mixed success. A participant said he tried putting his vape out of sight, but it didn’t work very well and instead needed to employ a situation selection strategy discussed in the subsequent section,

the only thing that works for me really is just not buying one and being around it really. [Aaron, YA, e-cigarette use only, never smoked]

For a few determined participants, disposing of their e-cigarette devices by throwing it away was the best way to eliminate the temptation to vape, although this wasn’t enough for Kim, who found herself buying new e-cigarettes to replace the devices she had thrown out. [e-cigarette use only, previously smoked]

Participants also described other strategies to reduce vaping such as using nicotine alternatives like gum or patches, rationing use of their e-cigarette, and reducing the concentration of nicotine in their device over time. Participants rarely implemented penalties and rewards for themselves based on how well they limited their vaping. Participants often said things like, “the only penalty is guilt” [Zoe, adult, dual use] or “I penalize myself by abstaining from [the e-cigarette]” [Gabriel, YA, e-cigarette use only, never smoked]. Only one participant talked about using money saved from abstaining on other items as a reward.

Situation Selection.

About one third of participants reported using situation selection. The most common strategy was avoiding other people who vape or activities that encourage vaping:

I try to avoid a certain kind of company, you know the other heavy, heavy vapers. Something that works staying with people who don’t vape and staying myself inside. [Matthew, YA, dual use]

The fastest one for me is trying to restrict yourself from any activity that makes you vape. That works like magic. [Amir, adult, e-cigarette use only, never smoked]

Since these strategies require selecting a certain situation before active cravings, examples typically involved planned, intentional changes to daily activities. Another participant mentioned putting himself in an environment that restricts vaping by scheduling workouts at a certain time in the afternoon when he would typically vape:

Going to the gym and working out really works because I cannot [vape at] the gym. That would be inconveniencing other individuals. [Oscar, adult, dual use]

Aaron said that when he wanted to vape less, he avoided going into his suitemate’s room since they had an e-cigarette. Reflecting on what strategies worked for him, he added, “yeah so [it] usually takes me removing myself from situations where there is a vape.” [YA, e-cigarettes only, never smoked]

Other strategies

Several participants mentioned having rules about who they used e-cigarettes around or the times and locations where they vape. One participant explained how they had a rule against vaping in their house and tried to limit vaping to certain parts of their day [Alex, YA, dual use]. It should be noted that while most participants mentioned avoiding vaping around specific people, such as a relative who didn’t approve of vaping, few viewed this as an intentional strategy to control their vaping, so these instances were excluded from analysis.

Impact of Restraint Efforts

Participants shared various ways in which vaping restraint affected their health, moods, social activities, and free time. Participants indicated several negative short-term effects on mood such as increased crankiness, irritability, and anxiousness when restraining. A few participants mentioned that cutting back on vaping negatively impact their social interactions. For example, Sebastian [YA, e-cigarette use only, never smoked] mentioned that he used vaping as a means of interacting with others, as he often asked to use other people’s e-cigarettes.

Participants reported several positive effects of restraint including perceived improvements to health. One noticed improved blood pressure:

I can also physically tell when I’m limiting myself or reducing completely that my blood pressure is lower from checking, monitoring that. [Kim, adult, dual use]

In addition, many people noted that because they are looking to do something with their hands or mouth, they turn to eating snacks or drinking water and also noted changes in appetite. Some participants predicted that if they were to cut down on their vaping in the future, they would save money, have more free time, and enjoy feelings of freedom and independence from vaping.

DISCUSSION

All participants endorsed at least one strategy to control their e-cigarette use, even if they did not report trying to limit their overall pattern of use. Almost all participants changed a situation to make vaping more difficult (situation modification). Fewer participants used situation selection, which required planning ahead and often altered participants’ social interactions. Participants generally viewed these situational strategies as successful. The strategies of distraction and reappraisal were also partially successful in reducing vaping. More research is needed to understand the extent to which these restraint strategies are successful in reducing overall e-cigarette use. Participants who used willpower alone found it to be less effective or altogether unsuccessful. This is in line with previous research indicating that specific self-control strategies are more effective than relying on willpower alone.^21,33

Uncontrolled vaping was common despite many participants not characterizing their behavior as such. They oftentimes reported satisfaction with the amount they vaped but later expressed interest in cutting back. Most participants cited the ability to vape discreetly in public places, enjoy flavors while avoiding smoke and unpleasant odors associated with combustible cigarettes, and even the continuous nature of e-cigarettes as positive attributes that made vaping more appealing, potentially increasing or leading to uncontrolled use. The relative social approval of vaping and fewer immediate health consequences compared to cigarettes (e.g., coughing, shortness of breath) may have encouraged users to think less critically about vaping and subsequently reduced intentions to restrain.

Participants employed various restraint strategies including situation selection and situation modification to make vaping more difficult. This often occurred by planning ahead or taking direct action to reduce the impulse to vape, which may have allowed participants to feel a greater sense of control. Unsurprisingly, making alterations to one’s environment, whether by planning ahead or changing a tempting circumstance as it arose, seemed to be more successful than relying on willpower alone to limit vaping. This is in line with previous findings that individuals with high self-control actively minimize environmental temptation as a form of regulation.³⁴

Distraction was commonly endorsed and helpful for many participants in limiting vaping. The strategy was seen as most successful when participants shifted their awareness to a task that incorporated mental or physical exertion, or one that fostered social connection. Reappraisal, a purely mental strategy, helped participants reshape how they thought about vaping, often in relation to their health, as a means of reducing the amount they vape. The generally negative view of willpower suggests that people who vape need actionable steps beyond mere self-control to change vaping behavior.

The Process Model of Self-Control holds that restraint strategies can be combined and used at different points along impulse generation cycle. We did not ask participants about combining multiple strategies, but participants offered examples of naturally applying various strategies depending on their circumstances. While we applied just one restraint code to each strategy, some strategies shared similarities that should be further explored. For example, participants’ use of distraction sometimes included situational changes as a way of directing mental focus away from an active craving. More research is needed to determine how people combine strategies and the effectiveness of different combinations in controlling vaping. Cessation and control programs may support users in quitting or reducing e-cigarette use by empowering users to employ multiple restraint strategies. Furthermore, programs that rely too heavily on willpower may be unsuccessful in reducing or restricting e-cigarette use. Lastly, e-cigarettes should be viewed as products distinct from combustible cigarettes with unique characteristics that pose challenges for restraint.

While these interviews provided a novel, in-depth look at e-cigarette users’ perceptions and natural restraint tendencies, the themes and patterns identified through qualitative methods require further exploration through quantitative and controlled research, which also include adolescents. Additionally, data collection occurred during the COVID-19 pandemic. As a result, the generalizability of the themes and relationships discussed in the paper to other populations or time periods remains to be established. Our use of videoconferencing may have yielded some different results than in person interviews, though a new study showed advantages associated with the utilization of videoconferencing applications for research facilitation.³⁵ The study did not assess marijuana use in vaping devices; those who consume marijuana may have different perceptions of restraint strategies and their efficacy. The detail and depth provided by this small group of individuals suggests e-cigarette restraint could be improved with naturalistic behavioral and cognitive interventions and illustrates the need for research to confirm the efficacy of learned restraint strategies to reduce uncontrolled vaping.

Further research should evaluate the frequency of restraint strategies and measure correlated e-cigarette restraint outcomes to assess differences in success of individual strategies as well as combinations of multiple strategies to predict which are most effective. Differences in e-cigarette use patterns, including whether people use e-cigarettes with the intention of quitting combustible cigarettes, should also be investigated to determine the best restraint strategies for each group while preventing any unintended increase in combustible cigarette use. Additionally, future research could examine potential differences in restraint between users who intentionally limit their e-cigarette use and those who do not. The findings from this study provide ideas for intervention development to support e-cigarette users in implementing restraint strategies and elucidate characteristics of e-cigarettes and their use that may lead to increased appeal and subsequent uncontrolled use.

Highlights:

• People may experience uncontrolled vaping, or using e-cigarettes more than desired

• Strategies to limit vaping can be mapped onto the Process Model of Self-Control

• Proactive situational strategies are seen as effective in regulating e-cigarette use

What is already known on this topic

E-cigarette use, or vaping, is common in the US, especially among youth and young adults and poses health risks with long-term use. Little is known about how e-cigarette users self-regulate their vaping, especially since e-cigarettes differ from combustible cigarettes in ways that make vaping more appealing such as enticing flavors and lack of cues to indicate stopping.

What this study adds

This study contributes an exploratory view of adult e-cigarette users’ perceptions of their e-cigarette use as well as the strategies they employ to restrain use.

People who vape often have experiences of uncontrolled vaping. Many frequently succeed in restraining use when using strategies that involved planning ahead or altering their environment to reduce temptation and access to vaping products.

How this study might affect research, practice, or policy

Interventions to reduce e-cigarette use and dependence should consider leveraging strategies that users have already found help them successfully limit their use. Likewise, policymakers could alter environments and e-cigarette characteristics to improve self-control and reduce e-cigarette use.