An essay by Oliver Kershaw & Amelia Howard

There is a disconnect between the tobacco research community and the vape community. Both groups have almost totally divergent knowledge-base of the technology; the former based on its existing tobacco research agenda, the latter based on practical experience with the technology and through peer-learning and marketing.

We contend that vape is not an extension of the medical science paradigm or the tobacco control paradigm and, therefore, that the techniques used to (simultaneously) understand and tackle tobacco usage are wholly inappropriate in understanding vape. We are not saying that these established paradigms are illegitimate or irrelevant. But they do not work well when it comes to understanding user-driven technology, which, importantly, is also not an extension of the tobacco industry.

This has led to a continued and intractable divergence between the practice community that makes and uses the vape kits and the communities publishing research. It is still true to say, as it has been true to say since the technology appeared that the productive, and perhaps the only way, to understand vape is as a consumer.

Our current situation is not good: Regulations are being made based on a body of evidence that comes from the wrong expert community. Wrong because the evidence was generated from an epistemological position that is alien to consumer-driven, emergent technology - or technology more generally. Business decisions are being made based on the same flawed understanding. Once made, regulations will set vaping down a path that will be very difficult to reverse. There is little indication that regulatory decisions are being made with any meaningful understanding of the products or innovation ecosystem being regulated. If this does not change, the opportunity is lost in the United States.

In this first part of a two-part essay, we explore and try to demonstrate one way in which an ill-fitted research agenda leads to misrepresentation of the “real world” of vape. In the second part, we’ll look deeper at how research questions might actually uncover something that tells us how vape should be understood, regulated and innovated within.

Sticky Vape

One of the big takeaways from the E-Cigarette Summit was, it appears, the notion that vape isn’t “sticky” enough compared to cigarettes. Jonathan Foulds made this observation during his presentation, in which he stated that (from the P.A.T.H data):

“of those who have used an e-cig in the past 30 days, only 12.7% have NOT used another tobacco product in the past 30 days. i.e. 87% of current e-cig users are dual users with another tobacco product, mainly cigarettes.”

For sure, this does read like vape isn’t “transporting” vapers away from smoking in droves. It sounds like it’s failing. But there’s so much missing from the picture. 

The P.A.T.H picture

A couple of important observations to begin with: Fould’s figures are derived from the first wave of P.A.T.H data, collected between 2013 and 2014. As any vaper knows, there’s a chasm of difference between what was available then and what’s available now.

Importantly, though, is the perspective taken here: In the period September 2013 to December 2014, 13% of e-cig users were full-on “vapers” and had stopped smoking.

This particular era is what we refer to as: “the dawn of vape”. It had all just gotten going. Here’s a quick and dirty way of seeing what we mean, using Google Trends (Google Trends is a powerful tool – it gives you a relative picture of search volume on specific keywords).

There is a lot of bravado around P.A.T.H, and it’s easy to see why: It is a huge and detailed survey with an initial budget of nearly £100M. This is very impressive, but this kind of survey is problematic for the task of studying a developing technology like vape, precisely because its temporal resolution is poor, as compared with, say, Robert West’s (UK) Smoking Toolkit Study, which collects data continuously and analyses quarterly. In contrast, the STS costs just ~£160k per year.

A recent report by ECig Intelligence showed that ~25% of current US vapers are fully smoke-free. If this data generalizes ( Ecig Intelligence are confident in their sampling methodologies), we’ll have witnessed the doubling in “efficacy” (if we define efficacy as a full switch) in just three years. Important question: can any other technology aimed at ending smoking boast this?

Why is vaping less sticky than smoking?

Cigarettes are better at soliciting exclusivity from users than e-cigarettes. Why?

1. Established v.s. “beta” technology: Cigarettes are established and “work well” whereas vape kits are new, and vary in performance, in terms of nicotine delivery, ease of use, required maintenance, price, etc. The technologies have improved a great deal in recent years.
2. Smokers who use e-cigarettes may be promiscuous in their tobacco consumption habits to begin with. Forty percent of cigarette smokers use other tobacco products. It could be the case that cigarette smokers who try vape are those more inclined towards multi-product use in the first place. The inverse of this could also be a factor: the most “faithful” cigarette users who try vaping to reduce harm may be drawn to the most cigarette-like vaping models which are known to be underpowered and less effective at delivering nicotine. Most exclusive vapers have made a trade-off and gave up cigarette form-factor for more powerful, refillable systems, and “Faithful” cigarette users may not be open to this. It’s also been noted that those who use vaping product may be more dependent on tobacco products.
3. F.U.D. (Fear Uncertainty Doubt): When we talk about the adoption of any technology or consumer product, context matters. Between September 2013 to December 2014, the context was a massive push to pressure the FDA to assert jurisdiction over vape products. Moreover, states were beginning to tax the products and place limits on their use. So in this particular time-span, health groups and local health departments were collectively spending millions of dollars on vaping-specific counter-marketing and PR that had a wide reach. They specifically cast doubts on the “effectiveness” of the products in helping people stop smoking, highlighted numerous (exaggerated) dangers of vaping, while also making them out to be extremely lame. Perhaps the most disturbing feature of these campaigns was that they distorted the relative risk of vaping relative to smoking in the minds of many people who smoked, and who may have switched had they known the actual difference in risk.

An analyst’s view

Following the E-Cigarette Summit, May 8th, Wells Fargo analyst Bonnie Herzog reported in her “Takeaways From First U.S. E-Cig Summit” email that 87% of vape consumers continue to smoke and to smoke as much as they did previously:

“ e-cigs may be less harmful than cigs, but smoker satisfaction still remains weak – 87% of e-cig users still smoke the same amount of combustible cigs (dual-users) because they don’t find e-cigs to be as good or better at delivering nicotine”

To be clear, this is Bonnie’s takeaway. It’s not her opinion - it’s what she heard from the Summit. Now. Whatever someone like Bonnie Herzog takes away from an event like the Summit and reports to her audience matters, a lot, because it goes on to shape the opinion of numerous people in the business world. We believe that “what business people will hear” in this particular account is illustrative of the broken-ness of the process by which vape is being evaluated"”. So let’s unpack it.

“e-cigs may be less harmful than cigs, but….”

This is a neatly ironic article of speech for two reasons. The first, is that the relative risk of vaping compared to smoking is one of the few issues that established methods in nicotine and tobacco research are well suited to answer.

There is near uniform agreement in the expert community that vaping is indeed safer than smoking. We consistently see the word “may” floating around in statements about vaping’s harm relative to cigarettes. Seeing it here indicates that a poor comprehension of vaping technology is not the only problem in American tobacco control; it appears to be failing to translate its own knowledge to the public. To her credit, Bonnie addresses this later in her email with reference to the CDC’s duty to inform Americans of the difference. The Summit heard convincingly and overwhelmingly that vaping is safer than smoking.

The second bit of irony is that Bonnie’s “may” illustrates, and probably contributes to, a central reason that vaping is less “sticky” than smoking: smokers remain unconvinced or unaware of the radical difference in safety between cigarettes and vape.

“...smoker satisfaction still remains weak”

Vapers can be a little chauvinistic about vape. Vaping is not the only answer to the problem of smoking, despite the protestations of those who’ve found it works very well for them (and who can blame them?). For some people vape is simply not appropriate now and might not be ever. Smokeless tobacco and NRT products remain important for many. 

But Bonnie’s is an unfair characterisation. A great number of vapers have found vape is perfectly satisfying and works very well for them, and they were all formerly smokers. Not to mention those in the vaping community who have taken so enthusiastically to the technologies that they’ve participated in the process of innovating, freely share their knowledge with new users on forums, or have mobilized politically in attempts to save vaping from the threat of regulations that favour cigarette companies. Certainly for these former smokers, “satisfaction” did not remain weak. What’s going on here?

It’s all new!

Here’s how we think you should think about it: This is a new technology. We’re not even 10 years into the story.

The first “wave” of vape consisted of most smokers rejecting the nascent technology. But it also consisted of a core group of committed vapers, analogous to any type of tech enthusiast or product enthusiast who actively engaged in persevering with, adapting and improving the products.

Importantly, few smokers were satisfied with e-cigarettes in the beginning. And adopting the technology had far more to do with a willingness to live with (and often modify or adapt) something that was less than perfect. Trying vaping early on was more than consumption, it was participation, and some of this remains today in the currently available products. Of course, this participatory process was never going to suit everyone, and so plenty more smokers dropped out than persevered.

In other words, many people who “tried” vaping didn’t actually try vaping.

An important issue that has gone largely unremarked is that the people who don’t take to vaping don’t take to it for a whole range of reasons that vapers don’t have access to. Vapers don’t have access to these reasons - at least not by virtue of their experience in vaping - since these smokers don’t stick around in the vaping world (but vapers do precisely because they take to it!). 

The complex and many reasons that smokers may reject vaping have yet to receive serious consideration in the literature on use.

Lack of satisfaction may be one reason that smokers abandoned vaping early on, or why they “dual use” now - but there are likely several reasons. But if no one is asking, how can we possibly identify them?

Furthermore, the elephant that remains in the room: this technology “came of age” in the context of (nearly) zero marketing on its behalf and amidst a VAST amount of “counter-marketing”. Viewed this way, 13% of users having made the transition in 2013/14 should be startling and encouraging.

That said, Bonnie’s statement does raise the very real problem that the vaping market lacks a product that is as easy and satisfying as a cigarette. There is a lot more to be done to make vaping products satisfying to smokers. The question is: who is in the best position do the doing? The regulators? The cigarette companies? Other large companies? Or, maybe, the people using them?

"87% of e-cig users still smoke the same amount of combustible cigs (dual-users)"

We’ve gone through Kasza et al. (the P.A.T.H based study that Foulds referenced) and cannot see where the “same amount of combustible cigs” notion is drawn from, but let’s take it as “correct”.

The main problem here is: What’s a user? Sincerely, what is a user? Think it through for a minute.

There are likely several different user typologies in that that 87%. Here are a few:

1. Someone who tried a vape product in the period in question, hated it, stopped. They carried on smoking as before.
2. Someone who is using a vape product regularly where they can’t smoke, and smoking where they can smoke. They continue like this.
3. Someone who is using a vape product regularly where they can’t smoke, and smoking where they can smoke. At some point, they will smoke less and vape more.
4. Someone who enjoys vaping, but enjoys smoking too. They smoke as before, but add a new behaviour on top.

You can probably think of more. And you’ll be correct. Our point is that this blanket 87% figure would include an awful lot of behaviours.

So, let’s go back to the central question: “What is a user?”

It hasn’t been answered and is barely even considered in any of the official literature on e-cigarette use. Some researchers have thought about how “use” should be better measured, partly in response to some of the dire misuse of “ever-use data” from CDC surveys, and a partly in response to a late-in-the game recognition that not all measures of cigarette consumption transfer easily to vape.

The question needs to be asked at a much more basic level.

Whatever it is that is settled on that constitutes “a user”, it’s always going to involve a certain kind of relationship to the product. The four examples above make this plain. They highlight the need for a concept of “user” that can handle the heterogeneity of the category without rendering it meaningless. We propose conceptualizing use as a relationship between people and that which is being “used.”

How does one begin to understand the important things like: “what is it the ‘committed’ vaper gets out of vaping that ends up negating the transient state (that so many people find problematic) of ‘dual user’?”

“because they don’t find e-cigs to be as good or better at delivering nicotine”

At this point, it should be clear that we believe that reducing “efficacy” of e-cigarettes to the “extent to which they are as good or better at delivering nicotine” is nonsense, and we don’t think it’s what Foulds was saying.

That said, getting anything, including nicotine, out of an e-cigarette has a learning curve. Hajek et al., have shown that experienced vapers are very good at getting the nicotine from vape products. The problem is smokers aren’t learning to get the nicotine from the products. The factors preventing them from learning are numerous.

The decision to blame the technology is political, and, in the case of an evolving technology, somewhat premature: these factors are not the fault of the technology, they’re simply a fact of a technology that is still evolving.

Gimme something I can use:

Top-down innovation - the future that Deeming heralds

NRT; behavioural quitting programs; Blu/Vuse/Mark10; IQos; Allen Carr; Juul; a cigarette: They are all designed for a particular version of a consumer that wants a particular thing. Take NRTs. They are not designed with the person who smokes for satisfaction in mind. Well, they are, but only if we understand satisfaction in terms of a nicotine fix. NRT design will satisfy a consumer who understands the experience of satisfaction they get from cigarettes as defective, as an illness that needs treatment.

For this consumer, satisfaction comes from finally exiting the “recreational” tobacco market. Nicotine replacement is means to an end: a cure for wanting to smoke. Alternative relations to the product are eliminated, or understood “deviant.” NRT is designed to work within a highly regulated medical/pharmaceutical world, and presumes a consumer who is “ready to quit” and willing to tolerate such a world in pursuit of some state where they can be “free” from wanting or needing nicotine.

There’s a very good example of this. The “inhaler” product is almost universally loathed by smokers. It’s unpleasant to use and it looks awful. Incredibly, though, the poor visual appearance is by design. In its original incarnation, the inhalator was a “cigalike” because, similarly to early vaping products, the assumption was that a familiar form-factor would appeal to smokers.

The reason it was turned into something that smokers often refer to as “the tampon applicator”, is because the medical regulators believed that a cigalike would have abuse liability. So they made the makers make it ugly.

In contrast, vapes were functionally designed to supersede combustibles, where ST/NRT require a major change in the consumption of nicotine. Pretty obvious, right?

The problem is that “a better cigarette” is a hard thing to create. In many respects, as Oliver’s noted elsewhere, the cigarette has a mysterious appeal. It’s almost perfect in every way in the moment. And the convenience, the semiotics, the distribution of cigarettes are difficult for any new product to compete with. Admitting this is important, because when you do you can start to realise how hard a product the cigarette is to better.

How do we make e-cigarettes “stickier” for smokers? We need to think bigger than nicotine delivery. For a smoker to want to use a vape product instead of a cigarette, the vape must offer something more than a cigarette.

For many, vape already does this. How can we understand what makes this so? More importantly, how can we understand why vape becomes “sticky” for some and fails for others? We’ll look at that in Part 2.

 Amelia Howard Amelia is a PhD candidate in Sociology at the University of Waterloo (Canada). She is interested in the social, political and cultural dimensions of expert knowledge-making in science and technology. Amelia's dissertation research documents the response of experts, regulators, and incumbent industries to the growth of the independent vape market in the United States. Oliver Kershaw is the founder of e-cigarette-forum.com, the site where vaping began.