Vaping as an Off-Ramp From Smoking. In our next Science Lab session Dr Marewa Glover presents the key findings of the Voices of the 5% Study, a 4-year longitudinal qualitative study of New Zealand adults who used vapes but had no intention of quitting smoking.
Transcription:
00:05 - 00:57
[Summer Hanna]
But with that in mind, we unfortunately do need to move on, and so we'll move to our next author, Dr. Marewa Glover. Professor Glover is one of New Zealand's leading tobacco control researchers. She's worked on reducing smoking-related harm for 32 years and is recognized internationally for her advocacy on THR. She's a finalist of the New Zealander of the Year Supreme Award in 2019, recognizing her contribution to reducing smoking in New Zealand. In 2018, she was appointed tobacco section editor for the Harm Reduction Journal and also established the Center of Research of Excellence, Indigenous Sovereignty in Smoking, an international program of research aimed at reducing smoking-related harms among indigenous peoples globally. Today, she'll be sharing her insights on vaping as an off-ramp from smoking, a four-year longitudinal qualitative study of New Zealand adults.
00:59 - 06:26
[Video]
I am Professor Mārewa Glover. I am presenting vaping as an off-ramp from smoking, the final results of our four-year longitudinal qualitative study of New Zealand adults who had no near-term intent to stop smoking. New Zealand has a goal to reduce smoking prevalence to 5% or below by the end of 2025. Vaping was legalized in August 2020. Vaping has been promoted as a cessation tool or an off-ramp for adults who smoke. Our study investigated the factors undermining vaping as a robust off-ramp. We regularly conducted semi-structured phone interviews with participants starting in June 2020 and going through to March 2024. We asked them about their smoking and vaping status at each interview and their attitudes towards an experience of vaping. Due to early withdrawals of 62 individuals enrolled, this analysis is based on 60 participants. The participants were diverse. At baseline, they ranged in age from 19 to 81. 35 were female, 23 were male and two identified as non-binary. About half were New Zealand Europeans and almost half were Māori or Pacific Island people. At enrolment, 49 of the participants exclusively smoked and 11 smoked and vaped. At the final study interview, 14 participants had been lost to follow-up, 26 still smoked, including 7 who also vaped, 20, 33%, had discontinued smoking. We analysed the transitions from smoking to vaping and back again over time. Based on the last interview with a participant before they were lost to follow-up or when the study ended, 18, 30% did not change from exclusively smoking. 2, 3% remained both smoking and vaping. The remainder, 67%, reported between 1 and 6 changes in their smoking-vaping status over the study period. This figure shows the smoking status trajectories over time. In the upper box are the 49 who exclusively smoked at enrolment. The different colours show how they moved between smoking and vaping and to quitting. The number to the right hand of the lines represents the number of people in that trajectory group. The top line shows that 18 people continued to smoke up to their last interview. The lower box shows the 11 people who were smoking and vaping at the beginning of the study and the trajectories that they took. The variance in the lines shows that the trajectories were not uniform. The predominant initial transition was to move from smoking to both smoking and vaping. 17% switched from smoking to exclusively vaping, and 7% went from smoking to quitting, bypassing vaping. After these initial observed changes, 22% reported further switches in their smoking status to vaping, back to both smoking and vaping or quit, etc. there were four overarching categories of barriers to switching they appeared in this order over time the initial barrier was distance the vaping was just too different from smoking doubt was the second barrier and past those two barriers if a participant had tried vaping difficulty for example that vaping was too inconvenient That was the next category. The fourth theme was diluted. That is that vaping wasn't as satisfying as smoking, maybe because the nicotine was too low for them. However, we observed that many participants tried vaping or persisted with vaping across the years, suggesting that the barriers were not insurmountable over time. The in-depth qualitative insight collected over four years is a particular strength of this study. We also had a very high retention rate. In conclusion, the results support the assertion that vaping is an off-ramp from smoking, but it is being undermined by the identified barriers. Of concern, vaping was far less accessible to participants aged 55 and over compared to the younger people. Misinformation about the risk of vaping was a predominant barrier. To ensure that all subgroups, particularly older people and people with low interest in smoking cessation, can benefit from the health gains of stopping smoking, we need to identify interventions that can effectively counter the misinformation about vaping. You can read more about our Voices of the 5% study and the participant stories on our website.
06:32 - 06:37
[Summer Hanna]
And before we move into any questions, are there any further comments you'd like to make on the study?
06:37 - 09:45
[Marewa Glover]
Thank you, and thanks everybody for coming. I think that one concern that I had was about the older adults getting left behind. It used to be in New Zealand that the 18 to 24-year-old age group had the highest smoking prevalence. As a consequence of that, all of the policy in New Zealand has been focused on targeting that group with communication messages. So along comes vaping. They're fine with vaping. They like vaping. So as I said, people over 55, vaping has just been sort of too distant, especially people who have smoked long-term. So 41 years or more, they were far less likely to try vaping or shift to vaping or even both smoking and vaping. So that really came through quite strongly for me as a future concern. Basically, New Zealand could get to smoke-free, the highest prevalence will be among the oldest people, and they're the ones at the highest risk of smoking-related diseases and illness. So this study overcame many limitations of many studies in the literature, Many studies that say they're longitudinal are only like one year. The other thing that we were able to detect by following people for this period of time was that the transition period is longer than most of the studies that have been done. They do not follow up long enough. So they'll follow for, say, one year, and then this leads to them sort of saying, oh, people are going to relapse. It doesn't work. or all of the literature on people dual-using is based on very short studies. And this four-year view shows actually transition periods for people can vary. Some of them didn't move, you know, it's like 18, the average transition period was 18 and a half months. So not enough studies following people long enough to pick up how long it takes for somebody to transition, go to both smoking and vaping potentially. And then what we saw, anyone who was already in that both smoking and vaping group None of them relapse to smoking. So there's a lot of studies out there. They do not follow up. They're not following up people for long enough. And they're basing kind of very general statements that they apply globally, that vaping doesn't work, people become dual users, and they relapse, and they're severely limited, those studies, really.
09:46 - 10:09
[Konstantinos Farsalinos]
Thank you. I have a question. It relates to methodology. So you included 60 smokers. Some of them were also vaping initially, but you didn't recommend them to use any cigarette or anything. You were just observing their transition, but by themselves, without you giving any advice or suggesting to them to do the switch, right?
10:09 - 10:37
[Marewa Glover]
Correct, that's right. This is an observational study, so there was no intervention. Not even advice? No, no advice, just simply observational. And that is also a strength. There was no... We would not have been able to recruit people, as many people. We had to sort of stipulate, you will not be advised to stop smoking, you will not be...
10:37 - 10:41
[Konstantinos Farsalinos]
It's a typical real world scenario. I mean, that's the idea.
10:41 - 11:12
[Marewa Glover]
Yeah, we just wanted to follow what was happening for people as we ran up to 2025. And there's massive campaigns encouraging people to quit. A lot of pressure, a lot of negativity towards people who continue smoking. And we have a massive data on how they were feeling about what was being done about smoke-free 2025. Yes, we have a lot of information in their stories and I'm producing these in their own words on our website.
11:12 - 11:16
[Konstantinos Farsalinos]
What was the time period between interviews?
11:16 - 12:16
[Marewa Glover]
Every? We started with every two months. We were hoping to detect. We had another thing where we were going to sort of do carbon monoxide monitoring. This was all distant, so we would send the carbon monoxide monitor. COVID happened somewhere in there. We also have a paper published where we sent a... We sent a little digital recorder and we got them to record their voice at baseline. Each person received their own individual device to record, send it back, we cleaned it, etc. And we were hoping that when they said that they had quit... we would record their voice again. This was testing whether or not the changes in all the vocal cords could be used as a biomarker for distant studies that you're not seeing them in person. So that paper is published, and we learned quite a bit from that.
12:25 - 12:50
[Riccardo Polosa]
Apart from the age and sex, there are other determinants of trajectories of switching. A very important one is the product itself. Have you characterized the products that have been used in this population and tried to look at the sort of analysis, looking for determinants of success that was determined by the product?
12:52 - 14:10
[Marewa Glover]
Thank you for that. So because it was qualitative and observational, we don't have enough numbers to do those kinds of statistical tests. But people were using a range of devices. So for some older people, the simpler devices were simpler. So that's one of the barriers, difficulty, when they have to learn the pod devices where you can change the power and the... So, disposables were much simpler for people to learn how to use and would definitely, disposables definitely open it up and address that barrier of difficulty. But people were using a range and they moved over time as well, so they might try a pod device, they might get a box mod later, and then at some point they would get a disposable. Some people had three different So a box mod for at home relaxing and a pod device for another type of hit that they want at different times of the day and a disposable hanging around their neck on a cord for convenient just needed top up.
14:11 - 14:49
[Alexander Nussbaum]
Hi, Alexander Nussbaum from Philipp Morris Germany. Thanks for this presentation. You talked about barriers to switching to vaping. My question is, have you also looked at barriers to quitting entirely? I'm asking because, of course, you have, I think, 18 individuals who never quit. And also to indirectly advertise our publication that came out shortly on barriers to quitting smoking So I think that is an each need still why are people not quitting entirely? What's keeping them? I think our results are look at the book of the paper by Norbert at all at careers, but Just want to know if you looked at this
14:50 - 16:43
[Marewa Glover]
So these were people who had no near-term intent to quit, including people who never want to quit. So there were some that were very strong about that. They were never going to quit. They don't want to quit. They're not interested. So I was particularly looking at the barriers to vaping. One of the things I've noticed in the literature where people talk about the barriers and other qualitative studies, there's no framework. for categorising them. So many of the papers come up with a word based on a quote. So this comment on my four Ds, if you remember the four Ds from the tobacco control cessation, they said drink water, delay cessation, do something else. Anyway, so these four Ds are kind of super categories, where I saw in the literature, oh yes, well, they're all mixed up. So they're talking about something that's a distant one, a difficulty one, and I managed to put them in. And the other thing, of course, because I had the time, I managed to see that the distance was something that stops people even trying. And so they're actually across time that the difficulties or... the barriers change. So I hope that having a more super category, and it provides a framework for understanding the barriers and how they change over time. So there are barriers at every step, and especially the diluted one, where they would try something and it just was way too low in the nicotine, or could be too high, so...
16:44 - 16:48
[Konstantinos Farsalinos]
But don't forget that these were people, if I understood correctly, that had no intention to quit.
16:49 - 16:53
[Marewa Glover]
Across the whole... Initially, as baseline.
16:53 - 17:22
[Konstantinos Farsalinos]
They had no intention to quit? Because if you don't have an intention to quit, then every barrier seems much bigger than it really is. Because when you're motivated, you might consider these also as barriers, but they are much lower because you do have the motivation to quit. If you have included people who had no intention to quit, then any even minor difference may look really big to them because they don't care about quitting.
17:23 - 17:58
[Marewa Glover]
Definitely the people who had no intention to quit for them, even the distance wasn't an issue. But there were some, they were like, oh, I should quit, you know, but still, and especially for the older people, it's the technology. It was too different. They didn't understand it. The motivation, I probably would disagree with you that, you know, I don't think motivation is necessary. People were trying vaping anyway because everybody was vaping and, you know, so... you know about the accidental quitting.
17:58 - 18:10
[Summer Hanna]
It's great that we have a lot of robust discussion going on, but for any other questions or comments, please do follow up with Professor Glover after the session.