Subjective Experiences, Contexts, and Risk Perceptions of Very Low Nicotine Content Cigarettes and Electronic Cigarettes among People with Depression and Anxiety Disorders Who Smoke

Abstract

Background:

A low-nicotine product standard is currently under consideration by the U.S. Food and Drug Administration (FDA). This standard may be more effective if alternative, non-combusted sources of nicotine are concurrently available. This qualitative study explored the lived experiences of people with depression and anxiety disorders who used very low nicotine content (VLNC) cigarettes with or without e-cigarettes during a randomized controlled trial.

Methods:

We conducted semi-structured qualitative interviews with participants (N=20) as they completed a 16-week blinded trial of VLNC cigarettes with or without electronic cigarettes. Interviews explored 1) experiences with these products, 2) social and environmental contexts for use and 3) relative risk perceptions. Interviews were transcribed and analyzed using a hybrid inductive and deductive thematic analysis.

Results:

Concurrent access to e-cigarettes helped to ease the transition from usual-brand cigarettes to VLNC cigarettes. Some participants held misperceptions that VLNC cigarettes could reduce cancer risk whereas others did not. Participants expressed skepticism about the safety of e-cigarettes and the authenticity of the VLNC cigarettes. Smoking restrictions influenced e-cigarette use in some instances, but product preference was the overriding factor that influenced use. Participants did not note effects on psychiatric symptoms.

Conclusions:

Should a nicotine reduction policy be implemented with e-cigarettes concurrently available on the market, tailored messaging for people with anxiety and depression disorders may be necessary to educate people about and the availability of alternative sources of nicotine, such as e-cigarettes, as well as the relative risk of VLNC cigarettes and e-cigarettes.

1.1. INTRODUCTION

In June 2022, the FDA announced plans to go forward with a reduced-nicotine standard for cigarettes and certain other tobacco products (U.S. Food and Drug Administration, 2022). This plan is intended to reduce tobacco dependence and mortality in the U.S. Studies of very low nicotine content (VLNC) cigarettes, (i.e., cigarettes with 0.4 mg/gram of tobacco or less) in people who smoke have found reductions in cigarette use, nicotine dependence, and biomarkers of tobacco toxicant exposure (Donny et al., 2015; Higgins et al., 2020; Tidey et al., 2017, Tidey et al., 2019). These findings are important, because smoking rates among people with psychiatric conditions are elevated compared to the general population (Smith et al., 2014, Cook et al., 2014). Although people with mental health conditions who smoke are highly motivated to quit, more likely to engage in harm reduction behaviors, and more likely to make quit attempts than people without mental health conditions who smoke, they have lower quit success, likely due to higher nicotine dependence (Brose et al., 2020). People with depression and anxiety disorders experience greater abstinence-induced craving, withdrawal, and cigarette reinforcement when they relapse than people without psychiatric disorders (Tidey & Miller, 2015). Thus, effective harm reduction approaches, such as switching individuals to modified risk tobacco products, are needed to reduce tobacco-related health harms among these individuals.

Evidence from clinical trials indicates that people with and without psychiatric conditions who switch to VLNC cigarettes find them less satisfying and reinforcing than higher nicotine cigarettes (Tidey et al., 2017; Smith et al., 2017). Accordingly, substantial non-adherence with VLNC cigarettes has been reported (Snell et al., 2022). The availability of satisfying nicotine delivery alternatives, such as e-cigarettes, could increase the effectiveness of a nicotine reduction policy by making product tampering or illicit product purchasing less appealing (Smith et al., 2018). However, little is known about use and perceptions of VLNC cigarettes when e-cigarettes are concurrently available, particularly among people with psychiatric conditions.

Few studies have used qualitative methods to understand dimensions of VLNC use. A study conducted in New Zealand found that most participants found the cigarettes unpalatable but were in favor of them being offered as an option for people who smoke (Fraser and Kira, 2017). Another study explored expectations and subjective experiences among people without psychiatric conditions after 72 hours of exposure to VLNC cigarettes. Participants reported minor or no symptoms of withdrawal when using VLNC cigarettes exclusively. Risk perceptions about VLNC cigarettes varied, with some participants able to distinguish that VLNC cigarettes are less addictive but not less harmful, whereas others perceived VLNC cigarettes to be healthier than conventional cigarettes (Denlinger-Apte et al., 2021). As this study was conducted in a residential setting, contexts for VLNC cigarette use were not discussed. To our knowledge, no studies have used qualitative methods to explore subjective experiences, contexts, and risk perceptions of VLNC cigarette use among people with depression and anxiety disorders who have extended experience using VLNC cigarettes, with or without e-cigarettes.

This study used semi-structured in-depth interviews to explore the subjective experiences, risk perceptions, and contexts of VLNC cigarettes, e-cigarettes, and usual-brand cigarettes among people with depression and anxiety disorders after 16-week use of these products in a two-site blinded randomized controlled trial (Clinical Trials Registry, 2019).

1.2. METHODS

1.2.1. Research Design

This study investigated the experiences of a subset of participants from an ongoing trial that is investigating whether providing e-cigarettes enhances the effects of VLNC cigarettes on cigarette reduction in people with depression and anxiety disorders who smoke (Clinical Trials Registry, 2019). Participants were recruited from two states in New England using community-based advertisements from November 2014 to September 2017.

Inclusion criteria for the parent study include currently smoking 5 or more cigarettes per day (CPD) and past-year major depressive disorder, dysthymic disorder, generalized anxiety disorder, post-traumatic stress disorder, obsessive-compulsive disorder, or panic disorder with or without agoraphobia, or a lifetime diagnosis of one of the above based on the Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998) with self-reported treatment of prescribed medication or behavioral therapy. Participants are randomized to one of four study conditions for 16 weeks: 1) normal nicotine content research cigarettes only, 2) VLNC cigarettes only, 3) VLNC cigarettes + tobacco-flavor e-cigarettes, or 4) VLNC cigarettes + preferred-flavor e-cigarettes. Participants and staff were blind to the nicotine content of cigarettes throughout the course of the study, including during these interviews. The e-cigarette devices provided in Conditions 3 and 4, JUUL and Vuse Solo, are commercially available closed systems. E-liquids contained approximately 5% nicotine by weight. During the experimental period, participants were provided with a 14-day supply of research cigarettes (referred to as “Spectrum cigarettes”) equivalent to 150% of their daily smoking rate. Spectrum were not commercially available at the time of this study and were provided to participants in a white branded box. There was no warning label present on the packaging. During the experimental period, participants were asked to only use the study products and refrain from usual brand cigarette use. Participants were directed to return all unused products to the laboratory each week.

1.2.2. Qualitative Study

The qualitative study was initially open only to participants in Conditions 3 or 4 of the parent study, and later included two participants in Condition 2 due to delays experienced by the COVID-19 pandemic. Twenty-two participants were invited to participate in a semi-structured interview, conducted in English, as they completed the parent study (at Weeks 14–16) or at the time of parent study withdrawal. Twenty chose to participate. Interviews were conducted from March 2020 through May 2021 (enrollment was paused during a 6-month period due to the COVID-19 pandemic). The first two interviews were conducted in person and subsequent interviews were conducted over the phone due to social distancing restrictions. Institutional Review Board approval was granted by Brown University. Participants received $40 as compensation for their time.

1.2.3. Data Collection Procedures

The interview guide covered sensory experiences (overall perception, subjective experiences), harm perceptions, and contexts (places, times, restrictions, peers, income) of product use. The interview guide developed by TD, AH, and JT incorporated dimensions of the host, agent, vector, environment conceptual model for tobacco products (Giovino, 2008). The interview guide was then piloted with researchers who were not part of the study for feedback. Interviews were audio-recorded and transcribed verbatim using the transcription software Descript (Descript Software, 2020). The interviews ranged from 34 to 87 minutes with a median length of 50 minutes. Following the conclusion of each interview, field notes were written by hand by the interviewer (TD) to document important content and to engage reflexively with the data.

1.2.4. Data Analysis Framework

We used a hybrid inductive and deductive thematic analysis (Braun and Clark, 2006; Spiers and Riley, 2008). Our deductive approach was determined a priori by our existing research and inductively using interpretive phenomenological analysis (IPA) techniques. IPA is an idiographic analytical approach used to understand how people experience a specific phenomenon within a specific context (Smith et al., 2009; Chan, 2010). IPA has a dual focus emphasizing the unique characteristics of individual participants and on pattern of meaning across participants, to that end we used the following IPA methods including provisional narratives, numeration, abstraction and the IPA process known as function, which examines the interplay of themes and narratives by organizing them by their positive and negative attributes.

1.2.5. Data Analysis

The analytical codebook was developed through an iterative process of open coding. Audio transcriptions were checked twice to ensure accuracy and immersion in the data. Audio transcripts were listened to by two independent researchers to ensure accuracy of the translation software.

Interview field notes were reviewed and converted to word documents for further review in aggregate. Given that the interview guide was semi-structured, development of the analytical codebook was based on initial domains of inquiry (subjective experiences, risk perceptions and contexts). Open coding was also used to add additional emergent domains to the codebook. At 20 interviews TD and AD determined that a-priori themes had reached saturation. After the codebook was finalized, all cleaned transcripts were uploaded into the qualitative programming software NVivo (Nvivo Software, 2018) for thematic coding. For quality assurance, a research assistant cross-checked the coding of each transcript by looking at the coding stripes from Nvivo. Any coding mismatch was subsequently discussed in a quality assurance coding meeting and resolved.

Following thematic coding, summaries were written for each code in our codebook to engage with the relationships between the emergent themes and the initial domains of inquiry and to allow for adaptations. Themes and subthemes were identified and clustered using numeration and abstraction (Smith et al., 2009). Themes were organized to align with our a priori themes; emergent subthemes are included within major themes. We did not differentiate between Conditions 3 and 4 during the analysis. Quotes were selected that best illustrate each theme and speakers are differentiated using participant ID numbers denoting gender, age, and study condition. Contextualization was used to compare connections between emergent themes and subthemes (Smith et al., 2009). Provisional narratives identified as part of this process were tested and refined in this step through the process understood in IPA as function, which examines the interplay of themes and narratives by organizing them by their positive and negative attributes. Textual comparisons provided an additional opportunity to find other examples in the data for these narratives.

1.3. RESULTS

Detailed participant demographics are presented in Table 1. Participants (n = 20) were a mean age of 46.15 years old and 55% female. Most participants self-identified as White, Non-Hispanic. At baseline, participants smoked an average of 20.1 cigarettes per day (range 7–40) and had an average Fagerström Test for Cigarette Dependence (FTCD) score of 5.4 (range 0–9) (Fagerström, 2011). Major themes included VLNC Cigarette Subjective Experiences (sensory and non-sensory), E-cigarette Subjective Experiences (sensory and non-sensory), VLNC cigarette risk perceptions, E-cigarette Risk Perceptions, and Contextual Drivers of product preference.

Table 1.

Participant Demographics

Participant ID	Study Site	Study Condition	Gender	Age	Race	Ethnicity	Baseline CPD	Nicotine Dependence Score	Prior exposure to e-cigarettes	Had never used an e-cigarette regularly	Study Completion at time of interview
Z-A018	UVM	VLNC& E-cig	Male	38	Black/African American	Not Hispanic or Latino	31	3	Yes	No	Complete
Z-A019	UVM	VLNC& E-cig	Male	21	White	Not Hispanic or Latino	16	5	Yes	Yes	Complete
Z-A901	UVM	VLNC& E-cig	Female	65	White	Not Hispanic or Latino	25	6	No	No	Complete
Z-A902	UVM	VLNC& E-cig	Male	27	White	Not Hispanic or Latino	13	4	Yes	Yes	Complete
Z-A903	UVM	VLNC& E-cig	Female	64	White	Not Hispanic or Latino	11	0	No	No	Complete
Z-A905	UVM	VLNC& E-cig	Male	27	White	Not Hispanic or Latino	21	6	Yes	Yes	Complete
Z-A906	UVM	VLNC& E-cig	Female	35	White	Not Hispanic or Latino	21	7	Yes	Yes	Complete
Z-A907	UVM	VLNC& E-cig	Male	55	White	Not Hispanic or Latino	21	7	Yes	Yes	Complete
Z-A910	UVM	VLNC& E-cig	Female	64	White	Not Hispanic or Latino	16	8	Yes	Yes	Withdrawn
Z-A911	UVM	VLNC& E-cig	Male	56	White	Not Hispanic or Latino	21	7	Yes	No	Complete
Z-B004	Brown	VLNC& E-cig	Female	47	Black/African American	Not Hispanic or Latino	7	4	No	No	Complete
Z-B006	Brown	VLNC only	Female	55	White	Hispanic or Latino	13	4	No	Yes	Complete
Z-B014	Brown	VLNC only	Female	46	White	Not Hispanic or Latino	20	7	Yes	No	Withdrawn
Z-B901	Brown	VLNC& E-cig	Female	53	White	Not Hispanic or Latino	12	4	No	No	Complete
Z-B902	Brown	VLNC& E-cig	Female	61	Black/African American	Not Hispanic or Latino	20	7	No	No	Complete
Z-B903	Brown	VLNC& E-cig	Male	37	White	Not Hispanic or Latino	28	7	Yes	Yes	Complete
Z-B904	Brown	VLNC& E-cig	Male	44	White	Not Hispanic or Latino	40	5	Yes	Yes	Complete
Z-B905	Brown	VLNC& E-cig	Female	39	White	Not Hispanic or Latino	35	9	Yes	Yes	Complete
Z-B906	Brown	VLNC& E-cig	Male	38	Black/African American	Not Hispanic or Latino	20	4	No	No	Complete
Z-B907	Brown	VLNC& E-cig	Female	51	White	Not Hispanic or Latino	11	4	No	No	Complete

^*UVM = University of Vermont

^*Brown = Brown University

1.3.1. VLNC Cigarette Subjective Experiences

When asked about their subjective experiences, participants initially focused on sensory reactions. Most participants (n=12) held negative subjective responses about the study cigarettes, however, seven participants reported neutral responses and one participant found them very satisfying. Of those who reported negative subjective responses, taste and smell were the predominate sensory factors driving this perception, followed by perceived lightness. For example, one participant described the taste as:

“It tastes more chemical-y, than feeling tobacco-y, I feel like you guys tried so hard to neutralize the tobacco and the nicotine level that the integrity of the cigarette kind of changed”

ZA905, M, Age:27, VLNC & E-cig condition

Similarly, one participant described the smell very negatively:

“The smell was like burning trash.”

ZA019, M, Age: 21, VLNC & E-cig condition

In comparison other participants were more neutral when describing the study cigarette taste:

“It tasted like a light menthol cigarette, I kind of could tell that I was on the lower end and whatever it is they’re doing to subtract that nicotine, you can taste every bit of it”

ZB903, M, Age: 37, VLNC & E-cig condition

“It tastes fabricated, it actually tastes like a healthy cigarette. [laughs] I mean, I donť know if that sounds good.”

ZB907, F, Age: 51, VLNC & E-cig condition

Similarly, a few participants didn’t mind the study cigarette, were able to cope with it, or found it mildly satisfying at reducing their cravings:

“I kind of liked the flavor of the study cigarettes... they have the same taste as an Indian Spirit, but I canť afford Indian Spirits.”

ZB906, M, Age:38, VLNC & E-cig condition

“They [the study cigarettes] were a little lighter, maybe thaťs why I weaned off more [smoked less than her usual brand], my cigarettes Newport [were] a little stronger, but the study ones are a little lighter than that, but I dealt with it. I coped with it.

ZB004, F, Age: 47, VLNC only condition

“Uh, they [the study cigarettes] didnť seem as strong…Even though they were menthols. And they were shorter, but it did take the edge off when I wanted one, you know?”

ZA901, F, Age: 65, VLNC & E-cig condition

When asked to expand on their experiences with the study cigarettes beyond sensory experiences, participants related to the study cigarettes in two main ways; 1) perceived “authenticity” and 2) source:

“They definitely didnť feel like they were made by a tobacco company. They felt like they were made by a research or government company. You could tell that they’re not trying to sell them.”

ZA018, M, Age:38, VLNC & E-cig condition

“You donť know where something’s produced, it came in a white box, Spectrum. And I’m like, “what the heck are these things?”

ZB014, F, Age: 46, VLNC & E-cig condition

1.3.2. E-Cigarette Subjective Experiences

When asked to describe their subjective experience using the study e-cigarettes, participants were generally positive and described them as a useful tool that helped alleviate their nicotine cravings and withdrawal symptoms while switching to VLNC cigarettes during the study.

“I think most people are going to experience an issue, immediately, when they transition, an increase in cravings. But if you stick with it, you push through - iťll [the e-cigarette] certainly serve to reduce cravings.”

ZA903, F, Age: 64, VLNC & E-cig condition

“I think definitely a little the headache and irritability, the withdrawal symptoms. But not for long because I relatively quickly shifted to almost exclusively using the e-cigarette.”

ZA018, M, Age: 38, VLNC & E-cig condition

This differed from participants who voiced that the study e-cigarette could be used as a full substitute for cigarettes, however, most did not feel the two products were comparable. One participant indicated that his satisfaction with the study e-cigarettes was high enough that it could lead to overuse:

“I had never used an e-cig before, but I did end up really liking it as a tool. I think it is a tool that can be used to help people reduce their smoking habits. I think it requires a lot more discipline on the individual because there’s a lot higher potential for abuse with it.”

ZA902, M, Age:27, VLNC & E-cig condition

One participant described their satisfaction with the e-cigarettes due to its lack of odor and smoke:

“If I just needed a drag or a couple, I’d smoke in the house cause it doesnť give off like the odor or smoke.”

ZA901, F, Age: 65, VLNC & E-cig condition

A different participant described how her satisfaction with the e-cigarette was mixed, sharing that she really liked the flavor, but the product did not completely ameliorate cravings for her usual brand cigarette:

“It tasted delicious, like the flavor…the melon flavor that I picked out. I mean, if you took a drag off of it, it tasted good, but it didnť get rid of my craving.”

ZB905, F, Age: 39, VLNC & E-cig condition

In contrast, sensory reactions to the study e-cigarettes were not always positive. For example, one participant described a negative experience which caused him to stop using the study e-cigarette:

“I stopped using the e-cigarettes, it was giving me one of those really dry, annoying coughs that would stick around all day long.”

ZB904, M, Age:44, VLNC & E-cig condition

Participants also discussed their dissatisfaction with the e-cigarette product quality:

“It was satisfying, but there were definitely those occasions where I would want a regular cigarette. The frustration would come from either the cart wasnť working the best or it was busted.”

ZA905, M, Age:27, VLNC & E-cig condition

1.3.3. VLNC Cigarette Risk Perceptions

Participants held mixed beliefs about the harms associated with the study products. Nine participants felt that the VLNC cigarettes were just as harmful as their usual-brand cigarettes, two felt they were more harmful, and nine felt they were less harmful. Inaccurate perceptions about nicotine risks influenced participants’ risk perceptions about the study cigarettes. For example, a participant who inaccurately equated nicotine content with risk stated:

“I sort of assumed that the study cigarettes were a similar nicotine content to my regular cigarettes because I was smoking an ultra-light, so I assumed the risk to be the same.”

ZA903, F, Age 64, VLNC & E-cig condition

Other examples of inaccurate beliefs included:

“Yes, there may be possible like a slight risk reduction, but I donť think I am advocating that iťs a healthy alternative, maybe less terrible.”

ZA018, M, Age: 38, VLNC & E-cig condition

Other participants voiced accurate beliefs about VLNC cigarettes, that appeared to be based on their prior belief that all cigarettes are bad for one’s health:

“The tar and the nicotine and all that, but I’m assuming that they’re as dangerous as normal cigarettes.

ZB006, F, Age:5, VLNC Only condition

Another participant noted that reducing the nicotine content of cigarettes could lead to reduced smoke intake, which would reduce risk:

“I think the cancer risk for me mentally is associated with the volume of smoke you’re passing through your body. I donť know why. So, I think that if a person is reducing their nicotine levels and that makes them smoke less smoke. I believe that that could reduce someone’s cancer risk.”

ZA902, M, Age:27, VLNC & E-cig condition

1.3.4. E-Cigarette Risk Perceptions

Participants’ impressions of the health risks associated with e-cigarettes were also mixed. Four participants perceived e-cigarettes to be a healthier alternative to conventional cigarettes whereas five felt they were more harmful or equally harmful as cigarettes. Nine participants who received e-cigarettes did not comment on their harm. Of these nine participants, some of them used and others did not use the e-cigarette for various reasons. This participant perceived the e-cigarette to be a healthier alternative to his usual-brand cigarette:

“I liked the e-cig. I thought the e-cig was good. I would take the e-cig over my usual-brand…because it’s more clean. I feel like the smoke from it is cleaner than burning the cigarette.”

ZB906, M, Age:38, VLNC & E-cig condition

In contrast, this participant felt that e-cigarettes were more harmful than their usual-brand cigarette, due to firsthand experience from using them during the study, which they felt was confirmed by information they had seen on TV:

“It just confirmed everything that I was already thinking anyway. We’re Americans, we’re shown all these negative side effects for everything. I see on the TV, how you’re sucking metal in your throat and it kind of just confirmed what I’ve been seeing, you know? When I smoke a cigarette, I donť, that didnť happen. I might get a headache if I smoked too many cigarettes from a certain time, but my lungs donť do that.”

ZA019, M, Age: 21, VLNC & E-cig condition

Participants voiced that their risk perceptions about e-cigarette safety had changed after hearing about emerging health issues associated with e-cigarette use:

“We know that what it does to your body, your lungs, your body in general, the e-cigs was supposed to be a healthier alternative, but now we’re finding that it’s causing some other kind of issue that no one quite fully understands yet.”

ZB901, F, Age:53, VLNC & E-cig condition

Overall, there was little consistency across risk perceptions with e-cigarettes, suggesting that participants may lack information or have difficulty comparing the relative harms of these products.

1.3.5. Contextual Drivers of Product Preference

E-cigarette use contexts were influenced by convenience and perceived ability to circumvent smoking prohibitions. For example, this participant discussed the ability to vape in his wife’s car:

“When I’d ride with my wife. We do not smoke in her car. Period. But she can’t really say anything about the e-cigarettes cause I’m not smoking.”

ZA019, M, Age:21, VLNC & E-cig condition

Similarly, one participant expressed both aspects of e-cigarette convenience as well as ability to use them where smoking was prohibited, in the following statement:

“Definitely added a level, an ease of access, it didn’t go unnoticed if I wasn’t participating in the study right now, I’d probably be stepping outside to smoke in this 10- to-zero-degree Fahrenheit weather.”

ZA018, M, Age:38, VLNC & E-cig condition

In terms of perceived product convenience, e-cigarettes were also described as portable:

“I donť like smoking when I walk, but having my pocket e-cigarette so I can puff two times, then put it back in my pocket. I like to sit down and smoke. So it was convenient.”

ZA907, M, Age:55, VLNC & E-cig condition

And easy to use:

“Iťs easy to use - to screw the little cartridge in [to] the back [of the e-cigarette]. Iťs easy to carry around with you in your purse because iťs small. Honestly, I think iťs good.”

ZB905, F, Age: 39, VLNC & E-cig condition

When asked about instances of usual brand use during the study period, participants mentioned using their usual brand during contexts when they forgot their study products or accidentally ran out. Two participants brought up instances of high stress in which they were overwhelmed by family matters and the study products did not sufficiently help them manage their stress. For example, one participant described the need for her usual brand when dealing with the loss of her father:

“I do remember that one weekend, I had this huge spike in smoking cigarettes, like the day after he died, we were just sitting down on the back deck, smoking like chimneys.”

ZA903, F, Age: 64, VLNC & E-cig condition

Despite the extended availability of both products as part of the parent study design, no overarching pattern emerged when participants talked about their routine use of both products. After the initial period of sampling both products, participants randomized to Conditions 3 and 4 tended to use one product over the other based on personal preference, and decisions to use one product over were due to either sensory aspects or contexts.

1.4. DISCUSSION

Qualitative studies describing individuals’ experiences with VLNC cigarettes can provide insights into how a large-scale federal policy may impact the daily lives of subpopulations of cigarette users. In this study of people with depression and anxiety disorders who smoke, participants found VLNC cigarettes less satisfying than their usual brand of cigarettes, except for one participant who described the study cigarettes as very satisfying and better than their usual brand. This finding is consistent with prior studies (Tidey et al., 2017; Denlinger-Apte, 2021). Seven participants shared they were able to get a little to moderate satisfaction from the study cigarettes but were eager to go back to their usual brand at the end of the study. Primary drivers of VLNC cigarette subjective experiences were sensory aspects, such as taste and smell, followed by non-sensory aspects, such as product authenticity. There was little indication that VLNC cigarettes affected psychiatric symptoms, consistent with observations from clinical trials (Higgins et al., 2020; Tidey et al., 2017; Tidey et al., 2019), although two participants noted that they reverted to their usual brand cigarettes during times of high stress.

The level of satisfaction provided by e-cigarettes was higher than that provided by VLNC cigarettes but lower than satisfaction from usual-brand cigarettes. While flavors were a component of e-cigarette satisfaction, use was driven equally by other aspects, such as the ability to reduce nicotine cravings, lack of odor, convenience, and ability to use the e-cigarette when smoking is prohibited.

Participants had varied opinions about the harms of VLNC cigarettes relative to their usual-brand. As participants were blind to the level of nicotine in their study cigarettes, their risk perceptions of VLNC cigarettes appeared to be based on either their sensory experiences or their understanding of the risks of smoking in general. In prior studies, participants who were blind to the nicotine content of their study cigarettes appeared to base their risk perceptions on perceived nicotine content, cigarette satisfaction, and craving reduction (Pacek et al., 2018; Denlinger-Apte et al., 2019; Denlinger-Apte et al., 2021). Likewise, experimental studies have found that sensory experiences of smoke (taste, feel) mediate the relationship between cigarette nicotine content and smoking satisfaction under blinded conditions (Rose et al., 1985; Rose et al., 1999). Risk perceptions may have differed had participants known the exact nicotine content of the study cigarettes. As some participants voiced difficulty delineating levels of risk associated with VLNC cigarette use relative to their usual brand, a communication campaign that highlights that VLNC cigarettes, while less addictive, are equally toxic (Byron et al., 2019) may help to correct existing misperceptions. Messaging on the mortality effects of VLNC cigarettes is associated with more accurate risk perceptions of VLNC cigarettes (Differding et al., 2022), and messages conveying that quitting smoking would be easier with VLNC cigarettes may encourage smokers to quit (Duong et al., 2022; Ranney et al., 2022). Since skepticism about product authenticity may be driving participants’ perceptions of the product overall, messaging that conveys credibility may be particularly salient for this population.

Regarding contexts, instances of usual brand use were primarily reported as times of high stress when neither study product was adequate in fulfilling an individual’s cravings. Convenience (i.e., portability) emerged as a primary factor driving e-cigarette use. In addition, a key difference in the contexts where cigarette and e-cigarettes were used was based on people’s belief that they could use e-cigarettes in places where smoking was prohibited because it was easier to use the product in a discrete manner due to product specific factors like lack of odor. This finding suggests that many people may lack the knowledge that in many locations, non-smoking rules extend to e-cigarettes.

There were mixed levels of knowledge about e-cigarettes. Two participants stated beliefs that e-cigarettes are healthier alternatives to smoking and reported intentions to switch completely from cigarettes to e-cigarettes after the study. Other participants voiced skepticism or uncertainty about the relative risks of the products they used. Prior studies have reported that risk perceptions of e-cigarettes held by people with mental health conditions who smoke are not less accurate than risk perceptions of people without mental health conditions, although the poor overall accuracy is concerning (Smith et al., 2021).

A strength of this study is the use of hybrid thematic analysis to investigate dimensions of VLNC and e-cigarette experiences. A limitation is that interviews were primarily conducted over the phone, which prohibited the interviewer’s observation of non-verbal cues. Furthermore, data were collected over the course of a global pandemic our findings must be placed within this larger context, which created high levels of social isolation, stress, and financial hardship for many people.

1.5. Conclusion

E-cigarettes were found to ease the transition from participants’ usual-brand cigarettes to cigarettes with lower nicotine content among participants with depression and anxiety disorders. Participants in this trial held mixed beliefs about the harms related to low nicotine cigarettes, e-cigarettes, and their usual brand, suggesting that messaging to correct product misperceptions, highlight the availability of alternative sources of nicotine, and increase credibility of this new commercially available cigarette may be warranted should a low-nicotine product standard be implemented.

Highlights.

• Qualitative studies on very low nicotine content (VLNC) cigarettes are limited.

• We report on the experiences of 20 people with affective disorders from an RCT.

• Participants held mixed beliefs about study products compared to their usual brand.

• Concurrent e-cigarette use may ease the transition to VLNC cigarettes.

• Messaging on the relative risks of VLNC cigarettes and e-cigarettes is needed.