Evaluating Nicotine Levels Selection and Patterns of Electronic Cigarette use in a Group of “Vapers” Who Had Achieved Complete Substitution of Smoking

BACKGROUND: Electronic cigarettes (ECs) are alternative-to-smoking nicotine delivery devices; consumers (commonly called vapers) use them in order to reduce or completely substitute smoking. The European Commission has released a proposal for a new Tobacco Product Directive that might reduce availability of nicotine-containing products, including ECs. In this study, the EC use patterns in subjects who have completely substituted smoking with EC use were examined by personal interviews. The study focused on nicotine levels used in order to achieve smoking cessation, reported benefits, associated side effects, and estimation of EC dependence compared with smoking. METHODS: Participants were 111 subjects who had completely substituted smoking with EC use for at least 1 month. Smoking abstinence was validated by measuring blood carboxyhemoglobin levels. Nicotine levels at initiation of EC use, at time of smoking cessation, and at time of interview were recorded. Dependence potential was assessed by asking the first question of the Fagerström Test for Cigarette Dependence (time until smoking the first cigarette and until first use of EC in the morning) and questions about perceived past dependence on tobacco cigarettes and present dependence on EC. RESULTS: Forty-two percent of participants reported quitting smoking during the first month of EC use. Liquids with nicotine concentration >15 mg/mL were used by 74% of users at initiation of EC use, while 16.2% had to increase the initial nicotine levels in order to achieve complete smoking abstinence. Seventy-two participants (64.9%) reported that from the time of smoking cessation to the time of the interview (8 months median duration of EC use) they reduced the nicotine concentration they were consuming; however, only 12% of the total sample was using ≤5 mg/mL nicotine concentration at the time of the interview. Side effects were mild and temporary. The vast majority of participants reported better exercise capacity and improved olfactory and gustatory senses. Perceived EC dependenct was significantly lower compared to smoking. CONCLUSIONS: Nicotine levels appear to play an important role in achieving and maintaining smoking cessation in the group of motivated subjects studied. High nicotine-containing liquids were used while few mild and temporary side effects were reported. Proposals about regulation should consider the pragmatic use patterns of ECs, especially in consumers who have completely substituted smoking.