Contexts of cigarette and e-cigarette use among dual users: a qualitative study
Pokhrel et al. BMC Public Health
Contexts of cigarette and e-cigarette use among dual users: a qualitative study
Pallav Pokhrel 0
Thaddeus A. Herzog 0
Nicholas Muranaka 0
Sakshi Regmi 1
Pebbles Fagan 0
0 Cancer Prevention & Control Program, University of Hawaii Cancer Center , 701 Ilalo St, Honolulu, HI 96822 , USA
1 School of Public Health and Health Sciences, University of Massachusetts Amherst , 715 North Pleasant Street, Amherst, MA 01003 , USA
Background: Not much is currently understood regarding the contexts of cigarette and e-cigarette use among dual users. Proper application of e-cigarettes to smoking cessation or tobacco harm reduction would require an understanding of when and why dual users use cigarettes versus e-cigarettes. This study sought to elucidate the contexts of cigarette versus e-cigarette use among dual users. Methods: Twelve focus group discussions were conducted with 62 young adult current daily e-cigarette users [63 % men; mean age = 25.1 (Standard Deviation = 5.5)]. Almost all participants either concurrently smoked cigarettes or had been recent dual users. Data were analyzed following principles of inductive deduction. Results: Results indicated that dual users' use of cigarettes is influenced by particular activities (e.g., before/after eating), strong craving or need for stimulation (e.g., in response to stress), places/situations (e.g., when cigarette smokers are nearby; outdoors), use of other substances (alcohol, coffee), and unavailability of an e-cigarette when needed. In addition to particular activities and places/situations that are conducive to e-cigarette use, use of e-cigarette when cigarette is not available or where cigarette smoking is not permitted emerged as contexts specific to e-cigarette use. Conclusions: For habitual cigarette smokers wanting to quit tobacco smoking, switching over completely to e-cigarettes may require skills of cognitive-behavioral management. Future research needs to ascertain the characteristics of dual users who use e-cigarettes as cessation aids versus as cigarette alternative when cigarette is unavailable or smoking is not permitted.
Electronic or e-cigarettes are battery-powered devices that
deliver vapor which may be inhaled in the manner tobacco
is smoked. The vapor is released when a liquid—popularly
known as e-liquid or e-juice—is heated. The e-liquid is
usually a solution containing propylene glycol and/or
vegetable glycerin, nicotine, and flavor concentrates. Ready
consensus has been lacking regarding the long- and
short-term public health consequences of e-cigarette
use, including the effects of e-cigarette use on tobacco
use initiation, maintenance or cessation . However, it
is generally believed that e-cigarettes deliver fewer
toxins and carcinogens into the human body compared
with cigarettes and thus have potential for application
in tobacco smoking cessation or harm reduction efforts
. Recent reports indicate that e-cigarette use
prevalence rates among U.S. and U.K. adults are steadily
increasing over the past few years [3–5]. For example,
among U.S. adults, prevalence of ever e-cigarette use
increased from 1.8 % in 2010 to 13 % in 2013 [3, 5].
Of the U.S. adult current daily and intermittent
cigarette smokers, 30 and 34 %, respectively, are likely to
report current daily or occasional e-cigarette use . It
is not clear what proportion of cigarette smokers who
try e-cigarettes actually switch over completely to
ecigarettes, reject e-cigarettes or continue to use both
cigarettes and e-cigarettes (i.e., dual use). It appears that
relatively fewer adult cigarette smokers who try
ecigarettes persistently use e-cigarettes daily for a
substantive length of time (e.g., a month); the majority are
likely to either reject e-cigarettes or become intermittent
users . Further, only a few daily e-cigarette users
among adult cigarette smokers (e.g., 20 %)  may be
able to abstain from smoking cigarettes completely. The
© 2015 Pokhrel et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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majority of current cigarette smokers who use e-cigarettes
are likely to be dual users, although there is no clarity as
to for how long.
An obvious problem with the concomitant use of
cigarettes and e-cigarettes is that such dual use may help
perpetuate tobacco smoking habit . There are many
ways in which e-cigarettes may make the life of a
cigarette smoker easier. For example, because e-cigarette
vapor lacks the noticeable smell of tobacco, e-cigarettes
may be surreptitiously used in places where smoking is
not allowed. For the same reason, smokers who would
not smoke cigarette inside their homes may use e-cigarette
indoors, thus overcoming the need to step outdoors to
smoke. Lower perceived harm associated with e-cigarette
vapor and second-hand exposure to the vapor may further
promote the use of e-cigarettes indoors, including at home
and work-place. Thus by reducing inconveniences and
providing a means to deal with craving or withdrawal
symptoms when cigarette smoking is not possible,
ecigarettes may help smokers maintain their cigarette
Conversely, habitual cigarette use may be perceived as
a hurdle to smoking cessation among daily e-cigarette
users who are using e-cigarettes to quit smoking.
Smoking cessation or reduction is the most common reason
for e-cigarette use among adult cigarette smokers [8, 9].
However, research indicates that only smokers who are
older, more educated, and highly motivated to quit
smoking are able to completely replace cigarette
smoking with e-cigarette use [6, 10]. Thus far, very little has
been known about the contextual factors that contribute
to continued use of cigarette use among daily e-cigarette
users. For example, knowledge is limited regarding why
and when daily e-cigarette users use cigarettes. Such
knowledge is important to effectively employ e-cigarettes
in smoking cessation or tobacco harm reduction efforts.
Understanding the contextual factors that may function as
barriers in smoking cessation/reduction will help develop
strategies that may be used as adjuncts to e-cigarettes in
smoking cessation or harm reduction interventions. This
study was conducted to gain an in-depth understanding of
the contextual factors of cigarette use through focus group
discussions with current daily e-cigarette users the
majority of whom are likely to be past or current cigarette
smokers. In addition, we sought to compare the contexts
of cigarette versus e-cigarette use.
study with young adult (18–35 year old) e-cigarette
users. The sample was restricted to young adults because
of the increased vulnerability of young adults to both
cigarette and e-cigarette use [4, 11]. Interested
individuals telephoned the research site and were screened by a
research staff. They were invited to participate in a focus
group session if they met the study inclusion/exclusion
criteria. Participants were required to be 1) current daily
e-cigarette users; 2) between 18 and 35 years in age; 3)
fluent in English; and 4) able and willing to travel to the
research site. Verbal consent was obtained from
potential participants before the screening was conducted.
Five to six selected individuals were invited to
participate in one focus group session. Participants whose
friends or family members had also been selected to
participate in the study were invited to participate in
separate groups. Because the discussions focused on a
gender-neutral topic such as e-cigarettes, groups
convened were mixed-gender. Attempts were made to
balance the number of men and women in a group.
This study was approved by the Western Institutional
Review Board (WIRB). Participants were asked to visit
the research site with a government-issued ID and their
electronic cigarette product of regular use. Once the age
was verified, participants read the informed consent
form, provided written consent and completed a
selfreport questionnaire which included measures of
demographic characteristics (i.e., age, gender, ethnicity, and
annual household income), and e-cigarette use and
cigarette use behavior. Participants were explained
during the consent procedure that participation was
voluntary and all information they provided would be kept
confidential and their private, identifying information
would not be linked with the data they would provide.
Focus group discussions commenced immediately after
all group members had completed the self-report
questionnaire. None of the interested potential participants
who met the inclusion/exclusion criteria declined to
participate in the study.
Focus group discussion was selected as a research
methodology for this study because focus groups offer an efficient
way to explore and discover wide-ranging information on a
topic through discussions with individuals whose
experience with the subject-matter being studied is first-hand.
Focus groups have an advantage over individual interviews
in that interactions among participants in a group setting
add both depth and breadth to the data. In the current
study, total 62 individuals participated across 12 focus
groups over a period of 4 months, from November 2013 to
February 2014. On average, each focus group consisted of 5
individuals and each discussion session lasted for
approximately 1 h and 15 min. The same protocol was followed
across all sessions. After the initial “engagement” questions
(e.g., “How did you first come to know about e-cigarettes?”
“What were your first impressions of e-cigarettes?”),
participants were asked three sets of questions, of which only one
set concerns the present analysis. The main question was:
“If you currently smoke cigarettes, when do you smoke
cigarettes and when do you use e-cigarette?” The same
question was altered to address those who claimed to have quit
smoking cigarettes: “At the time when you were using both
cigarettes and e-cigarettes, when did you use cigarettes and
when did you use e-cigarettes?” Participants were asked to
provide contexts as well as the reasons for dual use.
All focus groups were moderated by the first author.
The moderator was accompanied by a note-taker
(third-author) in all sessions. The same person functioned
as a note-taker across all sessions. The note-taker noted
each participant’s contribution to the discussions as well
as his or her non-verbal behavior. All sessions were
audiorecorded. The note-taker transcribed the
audiorecorded data following each session. The
transcriptions were cross-checked against the audio-recording
and focus-group notes by the moderator. Identities of
subjects and places or events that might identify
subjects were excluded from transcripts. Next, the
moderator and the note-taker reviewed transcriptions, notes
and discussed areas of consensus and discrepancies.
Discrepancies were discussed with the second and
fourth authors, who did not participate in moderation
or data collection. The second and fifth authors
reviewed the transcriptions and reached conclusions
regarding discrepancies. Transcriptions were considered
to be ready for analysis after discrepancies were
addressed. Then the data were coded separately by the
moderator and the note-taker. The other members of
the research team independently reviewed the codes
and coding procedures. The research team met to
review the coding and coding procedures and address
discrepancies. Recruitment was stopped after the 12th
session because 11th and 12th group discussions added
no new information, thus implying data saturation.
Quantitative data were analyzed by using SAS (Version
9.3) software. The NVIVO software (Version 9) was used
to code, manage, and analyze the qualitative data. Data
were analyzed following the principles of inductive
content analysis . First, open coding was performed. The
moderator and the note-taker separately read the
transcripts, noting down each context related to cigarette or
e-cigarette use. At this stage, the maximum possible
number of context categories was generated separately
for cigarettes and e-cigarettes. Thus a list of codes was
created on an ongoing basis. Next, the codes were
grouped under higher order concepts. We looked for
cigarette/e-cigarette use contexts across focus groups
and identified convergent and divergent contexts. A final
master code list was created along with primary or
higher order code definitions up to the point of
saturation [13, 14]. We compared and contrasted the codes
for all 12 focus groups. Because our focus groups were
not stratified by gender or race/ethnicity, we report the
data for the multiethnic, mixed-gender groups used to
collect the data.
Table 1 summarizes participants’ demographic and
ecigarette and cigarette use characteristics. Participants
ranged between 18 and 35 years in age. More men were
represented in the sample than women and the sample
was ethnically diverse with approximately 55 %
representing Asian/Pacific Islanders. Forty one percent of the
participants had been using e-cigarettes for 1 year and
more and 41 % had been using e-cigarettes for 2–6
months. Approximately 26 % of the participants were
light e-cigarette users (i.e., vaped only few times a day)
and 56 % were heavy e-cigarette users (i.e., vaped
frequently or constantly throughout the day). Forty-eight
percent of the participants smoked cigarettes daily and
36 % smoked cigarettes occasionally. Thus, 84 % of the
participants were current dual users of cigarettes and
ecigarettes. Of the n = 10 participants who identified
themselves as current non-smokers, two participants
had never smoked cigarettes whereas eight participants
were former cigarette smokers. The former smokers
reported having smoked >100 cigarettes in the lifetime and
none in the past 30 days. In summary, 97 % of the current
sample represented current or former dual users.
Contexts of cigarette use
Table 2 lists the contexts of cigarette use that emerged
across the 12 focus groups, supported by quotes that all
authors agreed best exemplified the corresponding
context. The contexts could be classified into five primary
categories: strong craving/need for stimulation, activities,
places/situations, and use of other substances that cue
or encourage cigarette use, and use of cigarettes as
ecigarette substitutes. Each of these categories and the
contexts subsumed within them are described below.
This category includes contexts of cigarette use that are
characterized by strong craving or need for stimulation.
Four specific contexts were found: use of cigarettes 1)
when strong stimulation is needed (10 groups); 2) when
craving is strong (10 groups); 3) when stress is high (9
groups); and 4) as laxative (6 groups).
Native Hawaiian/other Pacific Islander
Length of time having been using e-cigarettes
Table 1 Participant characteristics (N = 62)
About 2–5 months
About 7–11 months
More than a month
Size of e-liquid container usually bought
Length of time a container lasts
Daily e-cigarette use behavior
Vape only few times a day
Vape frequently but only at certain times of the day
Vape frequently throughout the day
Table 1 Participant characteristics (N = 62)
Vape constantly throughout the day
Never smoked a cigarette
Smoked < 100 cigarettes
Smoked ≥ 100 cigarettes
Past-30-day cigarette use
Note. % values were rounded to the nearest whole number
Four contexts of cigarette use emerged that may be
broadly classified as activities that cue or encourage
cigarette smoking: 1) after/before eating a meal (5
groups); 2) after work-out (2 groups); 3) after waking
up/before going to bed (4 groups); and 4) after sex (6
Participants mentioned that they chose to, or were
influenced to, smoke cigarettes depending on places and
situations. Seven contexts emerged. Dual users reported that
they were more likely to smoke cigarettes 1) when cigarette
smokers are close by (8 groups); 2) when socializing with
friends (8 groups); 3) on the weekend/while partying (9
groups); 4) on special occasions (4 groups); 5) when not
scheduled to meet or see anyone (2 group); 6) when
outdoors (7 groups).
Participants mentioned that cigarette smoking,
compared with e-cigarette use, was preferred while
consuming other drugs or psychoactive substances, specifically:
1) alcohol (11 groups); 2) marijuana (2 groups); and 3)
caffeine (3 groups).
Some dual users mentioned that they smoked cigarettes
only 1) when an e-cigarette was unavailable (9 groups);
or 2) when switching between one e-cigarette to another
(2 groups). Participants in general agreed that regular,
uninterrupted e-cigarette use required vigilance and
planning. The e-cigarette devices would need constant
monitoring. For example, the users needed to make sure, before
they left home, that they had enough cartridges or e-liquid
with them and the battery was fully charged. If in the
Table 2 Contexts of cigarette use
When strong stimulation is needed
When craving is strong
After waking up/before going to bed
When cigarette or smokers are nearby
When not scheduled to meet anyone
On the weekend/While partying
When socializing with friends
When e-cigarette is not available
“And I just recently bought a pack of cigarettes, over the weekend, just because I had to
go to work at 5:00, and I only got two hours of sleep that night, so I was really off, like
super tired. So I went to work, and at my break, I went to buy a pack of cigarettes to
wake me up even more, so I could deal with customers and not seem tired. Because it’s
so immediate, the effect of nicotine.” (20 year old man)
“It’s kind of hard to quit cigarettes though, it gives you that craving and you absolutely
need it.” (23 year old woman)
“So there are times when I’m like, stressed out, or even if I’m just bored or had a long
day or will have a long day like today, I’ll definitely go out for a cigarette.” (28 year old woman)
“So in the morning if I have to poop, I need a cigarette. Because I need to relax my body
to get stuff out.” (25 year old man)
‘I think after you eat and you’re really full, cigarettes are better. Like for me I like it a lot
better than my e-cig.’ (30 year old man)
“Actually my favorite time to smoke cigarette is after a workout. Because you just worked
a lot of it out of your system, and then it hits you with the best head buzz, like you just
started it again.” (24 year old man)
“[I have] been vaping for six months. I still smoke cigarettes twice a day. Once in the
morning after waking up and once in the evening before going to bed”. (31 year old woman)
“After a meal or after sex the e-cigarettes don’t cut it, you know what I mean?” (33 year old man)
“And it depends on if cigarettes are near you. Like you said your roommate smokes, and
my husband, when he’s home, he smokes cigarettes. So if there are cigarettes in my house,
and they’re right there, it’s harder than if I just don’t buy them.” (33 year old woman)
“So I’m a professional musician, so after gigs, usually. And then at rehearsals. Yeah, can’t
avoid it.” (32 year old man)
“If I don’t have to see anybody for a few hours I’m going to smoke a regular cigarette.”
(26 year old female)
“I joke around it’s like I use e-cig to smoke indoors and use cigarettes to smoke outdoors.”
(35 year old man)
“I switch over to cigarettes on the weekend, when I am partying.” (22 year old man)
“Other people smoking. Like if you’re with a group, and people go, ‘Let’s go outside for a
smoke.’ Then you want to. It’s hard to be like, ‘I'll go with you, with my e-cig.’ I mean you can,
which is nice, but it’s easy to want a real cigarette in that situation.” (26 year old woman)
“When I’m drunk, I do prefer smoking cigarettes.”(27 year old man)
“But also the weed factor plays into it, because then I also need a real cigarette.” (22 year old man)
“I usually have to have a cigarette in the morning, when I’m drinking coffee.” (33 year old man)
“Like I said, I don’t have that urge to smoke. The only time I will smoke a cigarette is if I
go out drinking, and this will die on me. Then I go out and buy a pack, or if I want to
have a cigarette I’ll have a cigarette. But then I’m fine, I don’t feel the urge to keep going.”
(30 year old man)
“When I first started I quit smoking cigarettes for a good three or four months, I didn’t
have a single cigarette. And then I don’t know what happened, I had the little one like
that [e-cigarette], but it just wasn’t doing it for me, it wasn’t strong enough. So I switched
to the bigger one. But in that time period before I switched to the bigger one, I started
smoking cigarettes again.” (33 year old woman)
middle of a party or a concert the battery died or they ran
out of cartridges or e-juice, finding another e-cigarette
was not as easy as finding another cigarette. Participants
mentioned that the first few e-cigarette devices they
experimented with were unsatisfying or of poor quality.
As they switched between devices while trying to find the
one they liked, in between, they continued to use
Contexts of e-cigarette use
Table 3 lists the contexts of e-cigarette use that emerged
across the 12 focus groups, supported by quotes that all
authors agreed best exemplified the corresponding
context. Overall, the contexts could be classified into three
broad categories: activities that encourage e-cigarette
use; places/situations that encourage e-cigarette use; and
use of e-cigarettes as tobacco substitutes.
Participants identified two activities that were conducive
to e-cigarette use as opposed to cigarette smoking: 1)
before or during work-out/physical activity (8 groups); and
2) when working (5 groups). Participants in general
agreed that e-cigarette use was more conducive to
physical activity. Specifically, participants mentioned that
unlike cigarette smoking, e-cigarette use during or before
physical activity did not affect their ability to perform.
Cigarette smoking, on the other hand, made them feel
“drained-out” and weak and adversely affected their
breathing. Participants found it more convenient to use
e-cigarettes while working. Unlike cigarette, e-cigarette
use did not require them to take breaks to smoke.
Coworkers were reported to be tolerant of their using
ecigarettes as they worked.
Table 3 Contexts of e-cigarette use
Dual users mentioned that certain places or situations
were more conducive to e-cigarette use than cigarette
smoking, specifically: 1) at home/indoors (11 groups); 2)
when alone (4 groups); 3) inside a vehicle (9 groups); 4)
when there is no time to take a shower after “smoking”
(2 groups). Participants generally agreed that e-cigarette
use was more suitable for indoor use: the vapor did not
smell as bad and the risk of second hand exposure was
perceived to be minimal. Participants mentioned that
their non-smoking family members disapproved of their
smoking cigarettes indoors. However, the same family
members did not mind their e-cigarette use indoors. In
addition, some of the parents among the participants
reported that while they would not smoke cigarettes
around their children, they freely used e-cigarettes
around their children at home.
Dual users preferred to use e-cigarettes while in their
private or work vehicle. They reasoned that smoking
cigarettes in the car made the car smell bad. With
ecigarettes, one did not need to worry about the smell.
The absence of cigarette-like smell also encouraged
some dual users to use e-cigarettes when they did not
have the time to take a shower after smoking. These
dual users did not like the smell of cigarette on them.
They were discreet smokers who smoked cigarettes only
Before/during work out or physical activity
“I use e-cig when I am engaging in more healthful activities.” (26 year old woman)
When cigarette is not available
When hookah is not available
When smoking is not allowed
“So it’s like when I’m working I can’t smoke a regular cigarette where I’m working at, so
I can smoke this indoors. So when I’m not on break, and then when I’m on break, I switch.”
(28 year old woman)
“My family, they don’t smoke. So it’s basically if I want to smoke I have to smoke my
e-cigarette and not a real cigarette, because I can’t smoke in the house. And of course
I’m not going to go outside and smoke a real cigarette in the rain, because that’s not
going to happen.” (28 year old man)
“Sharing e-cig is kinda gross. I mostly use e-cig when I am alone.” (22 year old man)
“He went back to traditional cigarettes, and then he still uses his e-cig in his company
van and stuff. Because he can’t smoke in there.” (26 year old woman)
“When I don’t want to have to shower right after—e-cigarettes I like because I can
smoke it, when I’m not stressed out it takes the edge off, and then I don’t stink.”
(30 year old woman)
“Yeah when I don’t have cigarettes, I use my e-cig.” (24 year old man)
“I like hokaah too. Because of the flavors. And e-cigs are like mini-hookah to me,
without all the hassles of a hookah.” (23 year old woman)
“But cigarettes still, they fight the edge or what not. I’m smoking these, like the Logics.
These Logic things are like ten bucks and last, it’s supposed to be like a carton… not a
carton, but a pack of cigarettes, something like that. I’ll smoke one of those, keep it in my
pocket at all times, you know what I mean? If I’m on the bus, chilling in the mall somewhere,
as soon as I get out and there’s fresh air and I can smoke a cigarette, guarantee that cigarette
is coming out of my pocket” (35 year old man)
if they were not meeting anyone or had a chance to take
a shower and change clothes after smoking. Some dual
users believed smoking cigarettes or other tobacco
products such as hookah to be a social activity. They
perceived e-cigarette use to be essentially a solitary activity.
An e-cigarette was thought to be more personal, not as
easy to share as a cigarette or hookah.
Across focus groups, 3 contexts emerged where
ecigarette was likely to be used by dual users as a
substitute for cigarettes or hookah. These comprised use of
ecigarettes 1) when cigarette is not available; 2) when
hookah is not available; and 3) when smoking is not
allowed. Dual users who in general preferred cigarette or
other form of tobacco smoking to e-cigarette use tended
to use e-cigarette as a cigarette or tobacco substitute
when cigarette or hookah was not available and/or when
smoking cigarette or hookah was inconvenient or not
permitted. These dual users used e-cigarettes to overcome
craving temporarily until they got the opportunity to
smoke tobacco. In the case of hookah users, however,
ecigarettes were mentioned to provide a much more
Based on the current findings, it appears that cigarette
smokers switching over to e-cigarettes may continue to
use cigarettes when facing strong craving or the need for
strong stimulation, until they find an e-cigarette device
that satisfies such needs. Dual users seem to prefer
cigarettes over e-cigarettes in situations where the need for
the physiological effects of nicotine is paramount.
Cigarettes are known to deliver nicotine more efficiently into
the human body than e-cigarettes [15, 16]. Nicotine is a
stimulant that increases the arousal of the central
nervous system (CNS) and the sympathetic nervous system
(SNS). Also, nicotine is an addictive substance that
produces reinforcing effects by enhancing dopamine release
in the brain’s reward pathways . Because of their
better nicotine-delivery efficiency cigarettes may better
satisfy smokers’ craving than e-cigarettes  and
provide more immediate, intense stimulation. In addition,
cigarettes’ better nicotine delivery efficiency may be
why dual users prefer cigarettes over e-cigarettes to
relieve stress, to enhance the reinforcing aftereffects of
food, sex, and physical activity or to use as laxatives.
Further, for some dual users the nicotine delivered
through cigarettes appear to provide the right level of
relaxation and stimulation, before going to bed and
after waking up, respectively. Although it is not clear
how the reinforcing effects of nicotine as a stimulant
help smokers relax or alleviate stress, smokers
commonly report smoking cigarettes as a means of
coping with stress .
Social influence may be an important barrier for
cigarette smokers trying to substitute cigarette smoking
with e-cigarette use. Mere physical proximity to
individuals who possess or are smoking cigarettes may strongly
encourage cigarette smoking among dual users. In
addition, in social contexts where dual users are actively
interacting with smokers, they may be directly or
indirectly pressured into smoking cigarettes.
Dual users may show a variety of cigarette use
patterns. Some dual users may use e-cigarettes throughout
the week and use cigarettes on the weekend only; when
they are likely to be partying with friends—possibly
other smokers—and drinking alcohol. Other dual users
may use e-cigarettes continuously for months and
choose to use cigarettes on occasions that they consider
to be special (e.g., New Year, birthday). Yet others seem
to use cigarettes more frequently but secretly: they may
smoke cigarettes in private when they can keep the
smoking discreet but when interactions with people are
imminent they may prefer to use e-cigarettes.
Use of addictive substances such as alcohol, caffeine,
and marijuana may encourage cigarette smoking among
dual users. Co-use of cigarette and alcohol, cigarette and
marijuana, and cigarette and caffeine is widely prevalent
[20, 21]. Cigarette smoking is believed to enhance the
reinforcing effects of alcohol, marijuana or caffeine [21–23].
The stimulating effects of nicotine perhaps contribute to
the increased subjective reinforcements associated with
co-use. Thus, skills managing other substance use may
matter greatly while trying to substitute cigarette smoking
with e-cigarette use. In general, smokers attempting to
quit smoking with the help of e-cigarettes may benefit
from cognitive-behavioral skills training. For example,
planning and vigilance seem important for regular,
uninterrupted e-cigarette use. When e-cigarette users feel the
urge to vape and are unable to use their e-cigarette devices
for one reason or another, cigarettes serve as an easy
substitute. If e-cigarette users are trained to manage their
ecigarette devices they may be more likely to have the
products available to them when needed. This study did not
probe participants’ views on the use of conventional
Nicotine Replacement Therapy (NRT) products as substitutes of
e-cigarettes when e-cigarettes are not available. It may be of
interest to future research to determine e-cigarette users’
receptivity to conventional NRT products as substitutes for
e-cigarettes when e-cigarettes are not available.
An important point to note is that not all dual users
are cigarette smokers using e-cigarettes to quit smoking.
There are dual users who use e-cigarettes
opportunistically as cigarette substitutes. Contexts of e-cigarette use
highlighted by the current findings elucidate such
opportunistic use of e-cigarettes. E-cigarettes are a more
convenient and discreet alternative to cigarettes for
indoor use and in situations where tobacco smoking is either
illegal or socially indiscreet. E-cigarette vapor does not
smell as harsh as cigarette smoke and does not linger in the
surrounding for long. Moreover, e-cigarette vapor is
generally perceived to be less harmful than cigarette smoke 
and to involve lower second-hand exposure risks .
An interesting finding of the current study is the use
e-cigarettes as a hookah substitute. The smoke and
vapor delivered by hookah and e-cigarettes, respectively,
are both usually flavored. However, it takes time to set
up a hookah. For example, the hookah has to be
assembled and the coal has to be lit properly. Besides, for
young adults, hookah smoking is a social activity;
engaged in as a group. Participants indicated that hookah
smokers preferred using e-cigarettes when they did not
have time to set up a hookah or when they were alone
and felt the urge to smoke.
The current findings have important implications for
future research. Clearly, future research needs to
determine what proportion of smokers who try e-cigarettes
continue to use e-cigarettes to control versus aid their
smoking behavior. Next, patterns and contexts of dual
use needs to empirically studied through daily
assessments in dual users’ natural environments. Such
research would give a clearer picture of how different
types of dual users use cigarettes and e-cigarettes. Such
research would also help clarify the relative importance
of different contexts in hindering smoking cessation or
aiding continued cigarette smoking.
There are limitations to this study that need to be
considered. One of the limitations is that participants across
focus groups represented different types of duals users.
For example, some participants were former dual users
whereas others were current dual users. Some dual users
were trying to use e-cigarettes to quit or reduce cigarette
smoking whereas others were confirmed cigarette smokers
who used e-cigarettes opportunistically, for convenience
(e.g., indoors) or to deal with withdrawal and craving in
situations where smoking cigarettes was not possible.
Further, there might have been dual users in the sample who
had previously quit smoking but had relapsed because of
e-cigarettes. We failed to identify those dual users.
Identifying such dual users would better elucidate contexts of
cigarette and e-cigarettes use among relapsed ex-smokers.
In general, it would be desirable to have the discussions
separated by the types of dual users. Because the
discussions were not thus separated, in-depth study of dual use
contexts pertaining to each dual user type was not possible.
This limited the scope of our findings. Secondly, we did not
collect data on patterns of dual use. For example, based on
the current data, a participant’s cigarette versus e-cigarette
use patterns over a period of time cannot be ascertained.
Because of this limitation, we were not able to identify how
different contexts may influence frequency of cigarette and
e-cigarette use. Thirdly, the present sample represented
young adults (18–35 years old) only, because of which
some of our findings may apply to young adults exclusively
and not generalize to adolescents or older adults.
Despite the limitations, this study is significant for
advancing the current understanding of how dual use of
cigarettes and e-cigarettes occurs. To our knowledge,
this is the first study to attempt to elucidate the contexts
of e-cigarette and cigarette use among dual users. The
findings have important implications for application of
e-cigarettes in smoking cessation or tobacco harm
reduction. First, the results highlight the fact that
cigarettes smokers trying to switch over to e-cigarette use
may frequently give in to the triggers and cues that
demand the more intense stimulating effects of cigarettes.
Second, continued cigarette smoking in one’s social
environment may contribute strongly to dual use. Smokers
trying to switch over to e-cigarette use may be easily
influenced into smoking cigarettes by friends and family
members who smoke cigarettes. Third, smokers trying to
replace cigarette smoking with e-cigarette use may need
to vigilantly manage their e-cigarette devices in order to
ensure that the devices are available when needed.
It is possible that effective application of e-cigarettes
in smoking cessation and/or harm reduction may partly
depend on improved technology on e-cigarettes’ part in
delivering nicotine efficiently. However, more
importantly, promotion of e-cigarette use in smoking cessation
or harm reduction may need to be coupled with
counseling focused on training smokers on how to manage
ecigarette devices and behaviors and situations associated
with tobacco smoking. In addition, research is needed to
understand the characteristics of dual users who are
attempting to quit cigarette smoking versus those who
are using e-cigarettes to aid smoking habit. The
opportunistic use of e-cigarettes to facilitate continued use of
cigarettes is obviously of concern.
PP conceived of the study, and participated in its design and coordination
and led the drafting of the manuscript. PF and TH participated in study
design, data analysis, interpretation, and manuscript preparation. NM assisted
in data collection and manuscript preparation. SR helped revise the
manuscript. All authors read and approved the final manuscript.
This study was supported by Food & Drug Administration/National Institute
of Health (NIH/FDA) Tobacco Regulatory Science Program in the form of
research grant [P30 3P30CA071789-15S3-Project 2] awarded to Pallav Pokhrel.
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