Interest in Electronic Cigarettes for Smoking Cessation Among Adults With Opioid Use Disorder in Buprenorphine Treatment: A Mixed-Methods Investigation

Abstract

Introduction

Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with Food and Drug Administration (FDA)-approved cessation aids, suggesting need for novel approaches. Electronic cigarettes (e-cigarettes) might benefit this population, but e-cigarettes’ acceptability for tobacco reduction or cessation among smokers in OUD treatment is not known.

Methods

A cross-sectional mixed-methods study of 222 adults in OUD treatment with buprenorphine in the Boston, Massachusetts metropolitan area was conducted in 2020. We used quantitative and qualitative data to investigate individuals’ experience with and interest in e-cigarettes and other methods for smoking cessation and assessed factors associated with interest in e-cigarette use.

Results

One hundred sixty (72%) of the 222 participants were past 30-day cigarette smokers. They most frequently reported having ever used nicotine replacement therapy (NRT; 83%) and e-cigarettes (71%) for smoking cessation and most often indicated interest in using NRT (71%) and e-cigarettes (44%) for future smoking cessation. In multiple logistic regression analysis, interest in using e-cigarettes for future smoking cessation was independently associated with having ever used e-cigarettes for smoking cessation, current e-cigarette use, and perceiving e-cigarettes to be less harmful than cigarettes (ps < .05). In qualitative data, many current vapers/former smokers reported that e-cigarettes had been helpful for quitting cigarettes. For current smokers who currently or formerly vaped, frequently reported challenges in switching to e-cigarettes were concerns about replacing one addiction with another and e-cigarettes not adequately substituting for cigarettes.

Conclusions

E-cigarettes had a moderate level of acceptability for smoking cessation among cigarette smokers in OUD treatment. More research is warranted to test the efficacy of this approach.

Implications

Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with existing smoking cessation tools, suggesting a need for novel cessation treatment approaches. In this mixed-methods study of individuals receiving medication treatment for OUD with buprenorphine in Massachusetts in 2020, we found a moderate level of acceptability of e-cigarettes for smoking cessation.

Introduction

While US adult cigarette smoking prevalence has declined to 14%, individuals with opioid use disorder (OUD) have a smoking prevalence of 70% or higher.^1,2 Medication treatment for OUD (MOUD) improves rates of OUD treatment retention and remission and reduces opioid-related mortality.³ However, many individuals receiving MOUD continue to smoke, and about half die of tobacco-related disease, making smoking cessation an urgent priority.⁴

OUD treatment is a potential opportunity for delivering tobacco cessation interventions because smokers receiving MOUD report interest in quitting smoking.⁵ However, they achieve abstinence rates less than half those of individuals without OUD who smoke,⁶ even when using Food and Drug Administration (FDA)-approved cessation pharmacotherapies.¹ Therefore, novel approaches to smoking cessation treatment, including harm reduction strategies, warrant investigation for individuals receiving MOUD.

Electronic cigarettes (e-cigarettes) are battery-operated devices that heat a nicotine-containing liquid to produce an aerosol that users “vape.” ⁷ Because e-cigarettes do not combust tobacco to generate smoke, e-cigarettes expose users to fewer toxic chemicals and health risks than cigarettes.⁷ E-cigarettes are effective smoking cessation aids among adults,⁸ but their acceptability and effectiveness for tobacco harm reduction or smoking cessation among individuals receiving MOUD are not known. A few studies have investigated the prevalence and correlates of e-cigarette use among patients receiving or entering OUD treatment,^9,10 or ever use of e-cigarettes for smoking cessation among individuals in SUD treatment.¹¹ However, no prior studies have investigated current use of and interest in e-cigarettes for smoking cessation among patients receiving MOUD. To fill this gap, we conducted a mixed-methods study of individuals receiving MOUD with buprenorphine (BUP). A quantitative survey assessed prevalence and characteristics of current smokers and their interest in using e-cigarettes for cigarette cessation, while qualitative interviews explored participants’ experiences using e-cigarettes to quit cigarettes to assess acceptability.

Methods

Design and Participants

The Vaping In Buprenorphine-treated patients Evaluation (VIBE) study¹² was a mixed-methods, cross-sectional, telephone survey that enrolled patients receiving BUP treatment at five Massachusetts General Hospital (MGH)-affiliated Community Health Centers (CHCs) in the Boston, Massachusetts metropolitan area. Eligible patients were English-speaking adults (>18) who had received a BUP prescription at a CHC in the past 2 months. Enrollment occurred from February to July 2020.

Measures

Quantitative Survey

We assessed age, gender, race/ethnicity, education, and health insurance. Participants were asked about ever and current (past 30-day) use of cigarettes and e-cigarettes. Current smokers were asked about daily cigarette consumption, time to first cigarette,¹³ intention to quit smoking (ie, in the next 30 days, 6 months, 12 months, >12 months, no plan to quit), and history of a past-year quit attempt (≥24 hours of nonsmoking with intention to quit).

Two questions assessed participants’ perceptions about the health risk of nicotine e-cigarettes. Participants were asked, “How harmful do you think e-cigarettes are/would be to your health?” with responses on a 5-point Likert scale. To assess comparative harm, participants were asked which was more harmful: smoking tobacco cigarettes or vaping nicotine e-cigarettes. Response options were “tobacco cigarettes,” “nicotine e-cigarettes,” “both equally harmful,” or “neither harmful.”

Current smokers were asked, “Have you ever used any of the following to help you quit smoking cigarettes?” Response options included nicotine replacement therapy (NRT), bupropion, varenicline, e-cigarettes, and behavioral support (in-person, telephone, internet, text, other). A similar question was used to assess participants’ current use of cessation aids and interest in trying these methods for smoking cessation in the future.

Electronic health records provided data on urine toxicology at the most recent CHC visit, total daily dose of BUP, and length of time in current BUP treatment.

Qualitative Interview

A subset of purposively selected participants, drawn from four strata defined by cigarette smoking and e-cigarette vaping status (current/former), completed a 20- to 30-minute qualitative telephone interview that was audio-recorded and transcribed for analysis. The interview investigated participants’ cigarette and e-cigarette use patterns, attitudes, and opinions. For this study, we focused on the qualitative probes querying participants about their prior experiences attempting to quit smoking cigarettes by using e-cigarettes to assess acceptability of this approach.

Statistical Methods

Participant characteristics were examined by past 30-day cigarette smoking status (yes/no) using chi-squared tests and t tests. Adjusted and unadjusted logistic regression tested the association between participant factors and two outcome measures, future interest in e-cigarettes for smoking cessation (yes/no), and future interest in FDA-approved pharmacotherapies for smoking cessation (yes/no), with NRT, bupropion, or varenicline defined as FDA-approved pharmacotherapies. Factors that differed significantly at the bivariate level (p < .10) were included in adjusted multiple logistic regression models. Quantitative analyses were conducted in STATA version 16 (StataCorp, 2019, StataCorp LLC, College Station, TX), with significance set at p <.05.

Qualitative interviews were iteratively coded by four study members (FKC, KMK, Hannah Malof, and JMS) using the constant comparative method.¹⁴ Coders were separated into pairs (FKC/JMS and Hannah Malof/KMK) and reviewed four transcripts to develop coding reliability and a preliminary codebook. Subsequent transcripts were coded and reviewed weekly. Once thematic saturation was reached, relevant themes/subthemes were extracted and compared by stratum.

Results

Participant Characteristics

The VIBE survey had a response rate of 43% with 222 patients completing a quantitative survey.¹² The sample was stable in BUP treatment, as evidenced by urine toxicology and an average of 3 years’ duration in current BUP treatment. Current cigarette smoking was reported by 72% of respondents (n = 160/222). Among smokers, 31% (n = 49/160) were current e-cigarette users (dual users). Current smokers reported smoking a mean of 12 cigarettes/day and 72% reported a quit attempt in the past year. Thirty-two percent of nonsmokers were current e-cigarette users. Participants had a mean age of 46 years, 51% were male, and 84% were white. Few significant differences emerged between current smokers and nonsmokers except for insurance status and BUP dose (Supplementary Table 1).

Quantitative Data: Interest in E-Cigarettes, Pharmacotherapy, and Behavioral Support for Cigarette Cessation

Ever use, current use, and future interest in use of each smoking cessation method among current smokers are presented in Figure 1. NRT was the most commonly reported smoking cessation method ever used, followed by e-cigarettes, varenicline, bupropion, and behavioral support. At the time of the survey, 46% of current smokers were using a smoking cessation aid. Among current smokers, 44%, 80%, and 3% were interested in using e-cigarettes, FDA-approved medications, and behavioral support, respectively, for smoking cessation (Figure 1).

Figure 1.

Smoking cessation methods by past 30-day cigarette smokers (N = 160). Bar labels represent percentages and error bars represent 95% confidence interval. Participants could check as many smoking cessation methods as applicable, thus responses within ever, current, and future interest are not mutually exclusive. Participants who responded “don’t know” to any items (n = 1 for bupropion ever use, n = 1 for NRT future interest, n = 1 for bupropion future interest, n = 8 for varenicline future interest, n = 1 for e-cigarette future interest) were excluded from the analyses. Behavioral support combines items that assessed in-person, telephone, internet, and telephone-based smoking cessation support. Current use was defined as any cessation medication use at the time of the telephone survey. E-cigarette = electronic cigarette; NRT = nicotine replacement therapy.

In multivariate logistic regression analysis, smokers who expressed interest in trying e-cigarettes for smoking cessation were significantly more likely to have previously used e-cigarettes for smoking cessation, be currently using e-cigarettes (dual use vs. exclusive cigarette use), and rated e-cigarettes as less harmful than cigarettes (vs. equivalent or more harmful than cigarettes) (Table 1). Smokers interested in using FDA-approved pharmacotherapies for smoking cessation were significantly more likely to have used them in the past, plan to quit smoking in the next 30 days and to be employed (vs. unemployed). We had an insufficient sample size to include interest in behavioral support as an outcome in multivariate analyses.

Table 1.

Interest in FDA-Approved Smoking Cessation Pharmacotherapy and Electronic Cigarettes for Smoking Cessation Among Past 30-Day Cigarette Smokers (N = 160)

	Future interest in smoking cessation methodsa
	Interest in e-cigarettes (N = 70, 44%)b		Interest in FDA-approved pharmacotherapies (ie, NRTs, varenicline, or bupropion) (N = 128, 80%)
	OR (CI)	aOR (CI)	OR (CI)	aOR (CI)
Demographic characteristics
Age	0.97 (0.94–0.99)	0.99 (0.95–1.03)	1.00 (0.97–1.04)
Female (vs. male)	1.10 (0.12–2.12)		0.75 (0.35–1.64)
White (vs. not)	0.57 (0.25–1.32)		0.89 (0.31–2.57)
Above high school (vs less than high school)b	0.90 (0.48–1.68)		1.15 (0.53–2.50)
Unemployed (vs. not) b	1.09 (0.58–2.07)		0.38 (0.16–0.92)	0.32 (0.11–0.92)
Medicaid (vs. not)	0.75 (0.40–1.40)		0.91 (0.42–1.98)
BUP treatment
Years in current BUP treatment	1.09 (0.86–1.38)		1.07 (0.80–1.43)
BUP dose (daily mg/g)	1.04 (0.99–1.09)		1.01 (0.96–1.07)
Smoking and vaping
Ever use of e-cigarettes for smoking cessation	4.27 (1.93–9.42)	2.96 (1.03–8.51)	1.59 (0.71–3.60)
Ever use of FDA-approved pharmacotherapy for smoking cessation	1.65 (0.55–5.06)		7.96 (2.58–24.51)	9.79 (2.66–36.03)
Past 30 days: average cigarettes smoked/day	0.98 (0.95–1.02)		1.05 (0.99–1.10)	1.04 (0.98–1.12)
Smoking within 30 min of waking	0.83 (0.43–1.58)		2.03 (0.91–4.54)	1.54 (0.55–4.37)
Plan to quit cigarettes in next 30 d (vs. not)	0.50 (0.23–1.08)	0.87 (0.27–2.75)	3.78 (1.08–13.19)	5.23 (1.29–21.19)
Dual cigarette/e-cigarette use (vs. cigarette only use)	26.76 (9.6–74.39)	16.3 (5.26–50.20)	0.67 (0.30–1.52)
Nicotine e-cigarettes are as or more harmful than cigarettes (vs. less harmful than cigarettes)	0.13 (0.06–0.30)	0.33 (0.12–0.92)	0.85 (0.38–1.90)
Absolute risk perception of e-cigarettes
Somewhat harmful (vs. not at all/slightly)	1.06 (0.35–3.28)	0.64 (0.16–2.51)	0.50 (0.12–2.12)
Very/extremely harmful (vs. not at all/slightly)	0.40 (0.15–1.09)	0.32 (0.09–1.15)	0.79 (0.21–3.01)

aOR = adjusted odds ratio adjusting for variables that differed significantly in bivariate analyses at p <.10; BUP = buprenorphine; CI = confidence interval; e-cigarette = electronic cigarette; FDA = Food and Drug Administration; OR = odds ratio. Bolded values represent p <.05 and italicized values represent p <.10.

^aParticipants were also queried about their interest in future behavioral support for smoking cessation. Six participants of the 160 current smokers (3%) indicated interested in future behavioral support and thus data are not displayed due to limited sample size.

^bOne participant responded “don’t know” and was excluded from the analyses.

Qualitative Data: Acceptability of E-Cigarettes for Cigarette Cessation

Thirty-one quantitative survey participants completed a qualitative interview, including six former smoker/former nicotine vapers, nine current smoker/current nicotine vapers, eight current smoker/former nicotine vapers, and eight former smoker/current nicotine vapers. The mean age was 43 years, 58% were female, 94% were white, and the length of time in current BUP treatment was 3 years. Qualitative themes and representative quotes probing participant experiences using e-cigarettes to quit cigarettes are provided in Supplementary Table 2.

The following factors were reported by the participants who had positive experiences switching to e-cigarettes from cigarettes: e-cigarettes replace nicotine/satisfy dependence, e-cigarettes mimic the behavioral aspects of smoking (eg, the hand-to-mouth, inhalation sensation in throat), and e-cigarettes are cheaper than cigarettes. Participants identified two different methods as helpful for switching to e-cigarettes to quit cigarette use: gradually switching to e-cigarettes from cigarettes, or completely and immediately switching to e-cigarettes.

Among participants reporting that e-cigarettes were not helpful for quitting cigarettes, the following themes were noted as challenges to switching to e-cigarettes: concerns of trading one addiction for another addiction, inadequate nicotine substitution, and difficulty judging the nicotine content of e-cigarettes.

When examining differences in qualitative themes by the four smoking/vaping status strata, participants who noted that e-cigarettes were not helpful for quitting cigarettes were current cigarette smokers who formerly vaped e-cigarettes. In contrast, many former smokers who currently or formerly vaped, described the utility of using e-cigarettes to quit cigarettes (eg, “The first time I used the JUUL, I was able to stop smoking cigarettes.”).

Discussion

E-cigarettes are novel nicotine-delivery devices with potential value for individuals receiving MOUD treatment who have high smoking prevalence and minimal success using available smoking cessation aids. E-cigarettes’ acceptability and effectiveness for tobacco reduction or cessation among smokers receiving MOUD are unknown. We conducted a mixed-methods survey of 222 Massachusetts adults receiving MOUD with BUP at a large healthcare system across five clinical sites to investigate use, interest in, and acceptability of e-cigarettes for smoking cessation. In our study, participants reported high rates of lifetime NRT and e-cigarette use for cigarette cessation (ie, 83% and 71%, respectively) and 44% and 80%, respectively, reported interest in these products for future cessation. Qualitative data suggested mixed acceptability of e-cigarettes for cigarette cessation.

As might be expected, individuals more interested in using e-cigarettes for smoking cessation were those with past or current experience using the devices, and, consistent with the Health Belief Model,¹⁵ those who perceived e-cigarettes to be less risky than cigarettes. It is notable that while 71% of smokers had used e-cigarettes in the past for smoking cessation, fewer (44%) were interested in these products for future cessation. Further, while having a plan to quit smoking in the next 30 days was associated with future interest in FDA-approved pharmacotherapies, it was not associated with future interest in e-cigarettes for smoking cessation. Current use of e-cigarettes for cessation and interest in using e-cigarettes for smoking cessation in our study, particularly by smokers who have not used e-cigarettes in the past, may have been dampened because data were collected shortly after the E-cigarette or Vaping-Product Use-Associated Lung Injury (EVALI) outbreak, which triggered a temporary total e-cigarette sales ban in Massachusetts,¹⁶ and during the federal and Massachusetts flavored e-cigarette ban during the peak of the COVID-19 outbreak. Prior data have suggested that EVALI heightened perceptions of e-cigarettes risk,¹⁷ and less is known about COVID-19’s impact on vaping behavior.¹²

Regardless, nearly one-third (32%) of participants who were current nonsmokers reported current e-cigarette use, and 44% of current smokers reported interest in e-cigarettes for future smoking cessation, which could suggest that e-cigarettes are a potential cigarette cessation strategy for this subset of patients. It was also encouraging that in qualitative data, former smokers who were current vapers noted that e-cigarettes had been helpful for quitting cigarettes. To date, two small pilot studies have been conducted providing adults with OUD with e-cigarettes to use in place of cigarettes to test cigarette reduction and cessation and have reported reductions in cigarette use.^18,19 However, future research is needed to thoroughly test the effectiveness of switching smokers with OUD to e-cigarettes. In our qualitative data, challenges experienced by current smokers and former vapers or current dual users of both products, which have been reported in other settings,²⁰ were concerns about sustaining nicotine addiction and inadequate nicotine substitution provided by e-cigarettes. Our qualitative data also suggest that participants vary in their strategies for switching to e-cigarettes (gradual vs. immediate). Further research on the effectiveness of e-cigarette substitution strategies may provide helpful guidance to those attempting to quit using e-cigarettes.

The VIBE study is a cross-sectional study and causality of associations cannot be inferred. Our data were collected shortly after the EVALI outbreak and during the COVID-19 pandemic, thus our results may not generalize to alternative contexts. Finally, e-cigarette devices are heterogeneous and vary substantially in nicotine delivery which could impact use and acceptability but was not considered in the present investigation.

This is the first study to investigate interest in e-cigarettes for smoking cessation in patients receiving MOUD. E-cigarettes appear to have a moderate level of acceptability for smoking cessation by cigarette smokers receiving MOUD, and more research is warranted to test the efficacy of this approach.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Funding

This work was supported by the National Institute on Drug Abuse (NIDA K12 DA043490; NAR) and sundry funds provided by NAR. The funding organization had no role in the study design, collection, analysis, and interpretation of the data, preparation of the manuscript, or decision to submit the manuscript for publication.

Declaration of Interests

NAR receives royalties from UpToDate, has consulted for Achieve Life Sciences, and consulted (without pay) for Pfizer. SK has received royalties from UpToDate. SW receives royalties from UpToDate and has received salary support from OptumLabs, Celero Systems, and Alosa Health. EP receives royalties from UpToDate. No other authors have conflicts of interest to disclose.

Data Availability

The data underlying this article will be shared on reasonable request to the corresponding author.