Social setting

Washington, DC is an informative setting in which to investigate the use of e-cigarettes in smoke-free environments. In April 2006, the DC City Council enacted a 100% smoke-free indoor air policy, and in January 2007 the policy was implemented in restaurants, bars, and nightclubs¹³. In November 2016, the DC City Council extended smoke-free indoor air policy to cover e-cigarette use, including use in the workplace, public transit, and sporting events¹⁴. It is important to note that while data were being collected for the current study, e-cigarettes had not yet been included in the DC smoke-free policy.

Sample and recruitment

Data were drawn from the parent study (‘Moment Study’), a three-week intensive longitudinal mixed-methods study. The Moment Study investigated e-cigarette initiation and cigarette displacement among adult daily smokers in Washington, DC, and is described in detail elsewhere¹⁵. Briefly, the Moment Study’s design featured concurrent collection of multiple data streams, including: 1) ecological momentary assessment, 2) geotracking, 3) three semi-structured interviews, and 4) biosamples. To elicit participants’ experiences and their views on using e-cigarettes in smoking restricted areas, only data from the semi-structured interviews are included in this paper, as they focus on the subjective perspective of the observed participants.

Adult daily smokers interested in using e-cigarettes were recruited via public online postings (e.g. Craigslist), paid advertisements (e.g. Washington Post Express), and flyers. Inclusion criteria included: 1) be 18 years or older, 2) reside in the Washington, DC metropolitan area, 3) report daily smoking of at least eight cigarettes a day for the past five years, 4) report no e-cigarette use in the past 30-days, and 5) not currently taking a smoking cessation medication (e.g. varenicline) or nicotine replacement therapy. Once enrolled, in-person procedures consisted of four office visits. All participants provided written informed consent and were compensated with up to $285 if they completed all study activities, including the three interviews. The Chesapeake Institutional Review Board approved all study procedures. For this qualitative analysis of initial understanding of e-cigarette use in smoke-free places/situations, three repeated-measures interviews (n=60) from 20 smokers in our sample of 107 were selected to be part of a subsample. This sample size reflects the ‘15 ± 10’ metrics for qualitative interview studies¹⁶.

Study materials

Following the first office visit (baseline interview), two packs of five disposable NJOY King ‘cigalike’ e-cigarettes (3.0% nicotine) were provided to participants at the end of the interviews conducted at the second and third office visits. Participants were provided regular or menthol ‘cigalike’ e-cigarettes, depending on their cigarette brand flavor preference. At the second office visit, participants were instructed to try a minimum of three e-cigarette puffs per day over the course of the week. At the end of the third office visit, participants received two additional five-packs and were instructed to use them as they desired (including not at all) over the course of the week.

Interview instruments

Three semi-structured interview guides¹⁷ were developed [by authors S.L.S. and J.L.P.], and included questions designed to examine how individuals understand the role of smoking restrictions on their e-cigarette use, and how social norms surrounding cigarettes and e-cigarettes affect product use (Table 1). The interview format allowed participants to respond extemporaneously to questions and discuss relevant topics at the second, third, and fourth office visits. The interview guide at the second office visit, focused on establishing rapport between the interviewer and participant, along with examining participants’ perceptions and utility of cigarettes in their lives, and perceptions of e-cigarettes. Sample questions included: ‘Tell me about yourself?’ and ‘What have you heard about e-cigarettes?’. As mentioned previously, two packs of five disposable NJOY King ‘cigalike’ e-cigarettes (3.0% nicotine) were first provided to participants at the second office visit, and again at the third office visit. The interview guide at the third and fourth office visits examined utility of e-cigarettes in their lives, including where they used e-cigarettes, others’ reactions, and perceived social norms. Sample questions included: ‘Can you tell me about the first time you tried an e-cigarette?’; ‘Where were you when you first tried an e-cigarette?’; ‘And how did it [using e-cigarettes] go the rest of the week?’. Probes included: ‘Describe the setting.’; ‘Were you inside or outside?’; ‘Were you alone or did you use them around others?’; and ‘How did others react?’.

Data collection and analysis

Two of the authors (S.L.S. and E.H.) were trained in qualitative interviewing techniques and conducted interviews separately at participants’ second, third, and fourth office visits. Each interview lasted up to 30 minutes and took place in a dedicated interview room at Truth Initiative’s Washington, DC office. The interviews (n=60) were digitally recorded with consent, professionally transcribed verbatim, edited to remove identifiers, cross-checked for accuracy, and imported into NVivo 10.0, a qualitative software package that aids in the organization, coding, and analysis of qualitative data¹⁸. Guided by thematic analysis methodology¹⁹, four of the authors (S.L.S., E.C.K., E.H., H.A.) independently read the transcripts and held debriefing meetings that involved writing preliminary analytical interpretations of the data, and developing a priori codes (e.g. initial e-cig use, bystander reaction) and emergent codes (e.g. militant smoker, smoke e-cig) in relation to the interview guide questions, transcripts, and research questions. Two of the authors (S.L.S. and E.C.K.) independently coded a subset of transcripts line-by-line and compared them, which led to additional codes. The codebook consisted of each code, its complete definition, and an example of a quotation from a participant’s transcript. These authors (S.L.S. and E.C.K.) independently coded the larger set of transcripts, and themes were generated iteratively during review of coded transcripts. After multiple rounds of coding, the first and second authors (S.L.S. and E.C.K.) determined that coding saturation had been reached²⁰, as new themes ceased to emerge. These authors also wrote analytical memos throughout the coding process and used them to confirm coding saturation. Lastly, the first author (S.L.S.) adjusted and re-checked the resulting themes against the transcripts²¹. All quotes are provided verbatim.

Participant characteristics

The sample (Table 2) comprised 10 women and 10 men (mean age M=37.9 years). Among participants, 10 self-identified as non-Hispanic Black and 10 self-identified as non-Hispanic White. Eighteen participants reported having smoked their first cigarette by the age of 18 years; 12 reported smoking menthol cigarettes; and 10 reported thinking about quitting in the next six months. Ten participants reported some college education; six reported college degrees; and four reported a high school degree as their highest level of educational attainment. Key themes are highlighted in Table 3.

Themes

The results that follow are organized in relation to the study’s two research objectives. These include: 1) Explore adult daily cigarette smokers’ experiences using e-cigarettes in the context of smoke-free places; and 2) Describe adult daily cigarette smokers’ perceptions of bystanders’ reactions to them using e-cigarettes in smoke-free places/situations. We expand and discuss these themes in the sections below.

Places of e-cigarette use

Throughout the narratives, participants reported using e-cigarettes in various public and private places, such as their homes/indoors, public transportation, private vehicles, workplaces, and bars/restaurants. One participant reported that he first used an e-cigarette after his second interview: ‘The first time [e-cigarette use]…I was walking down the street when I left here.’ (No.6, Male, 58 years). Another participant reported in her interviews that she was more likely to use e-cigarettes at home. When asked about where she used e-cigarettes, she replied: ‘I used them [e-cigarettes] mostly in my bedroom.’ (No.14, Female, 29 years). In addition to using e-cigarettes inside his house, a participant reported in his interviews that he used e-cigarettes in his personal vehicle: ‘I smoked [e-cigarette] in the car. I smoke it in the house. It was okay too because it doesn’t have that smell or nothing like…it’s just smoke.’ (No.19, Male, 27 years). The use of e-cigarettes inside his house and vehicle suggests that indoor places are more conducive to e-cigarette use than cigarette smoking because of the lack of tobacco smell.

Some participants described how they integrated e-cigarettes into their daily work routine. For example, one participant said: ‘on my breaks, it’s easier to do it [use e-cigarettes].’ (No.3, Female, 42 years). Another participant, who reported being employed at a restaurant, stated: ‘I’ve just been trying to do it [use e-cigarettes] where I like.’ (No.17, Male, 32 years). He explained:

For these participants, e-cigarette use at work was perceived to be convenient and beneficial, as an alternative to routine smoke breaks, and in turn, an uninterrupted work shift. Similarly, another interviewee stated: ‘It’s [e-cigarette] not dissatisfying to people that be around me, like at work. I told them what it was and everything and they said we don’t smell anything.’ (No.15, Male, 56 years). His viewpoint indicates that e-cigarette use at work is socially acceptable, because unlike cigarettes, e-cigarettes do not produce a smell that is offensive to his co-workers.

While some participants used e-cigarettes at work, other participants reported in their interviews that they restricted e-cigarette use to inside their house during the trial period. For example, one participant expressed uncertainty about e-cigarette use in places/situations other than her house: ‘I think because I’ve been smoking the e-cigarettes only inside and I don’t typically smoke inside anywhere, and I don’t know if it’s [e-cigarette use] allowed or whatever, I mean, all these other places. I know that I’m allowed to do that [e-cigarette use] at my house.’ (No.12, Female, 37 years). According to this participant, e-cigarette use inside her home is acceptable and free of unintended consequences. In the exchange given below, a participant conveyed to the interviewer that inside her house was more conducive to e-cigarette use than cigarette smoking, and how e-cigarette use in outside places would feel strange:

Her remarks suggest that bans on smoking in enclosed places have normalized cigarette smoking, not e-cigarette use, as typical outside behavior. She also states that she likes cigarettes more than e-cigarettes, and that she’s willing to go outside to smoke cigarettes, suggesting how a smoker might weigh the pros and cons of switching from cigarettes to e-cigarettes. Similarly, when asked if she used e-cigarettes outside, another participant reported that she only used e-cigarettes outside as a cigarette substitute when she ran out of cigarettes.

Perceived reactions from bystanders

In their second and third interviews, participants described trying to test and establish the social and spatial boundaries of e-cigarette use while in smoke-free places and recounted divergent experiences of their perceptions of how bystanders reacted to them using e-cigarettes in smoke-free environments. Perceived bystanders’ reactions were described as impartial, unfavorable, or favorable. According to one participant, the widespread use of e-cigarettes in public places is the reason bystanders did not react negatively or positively to his e-cigarette use: ‘I think because they’ve become more mainstream no one really reacted. Certainly, they didn’t say anything to me about using them.’ (No.19, Male, 27 years). Similarly, a participant who reported using e-cigarettes in bars to circumvent smoke-free polices, described having no reactions from bystanders. He said: ‘You see a lot of them [e-cigarettes] out at the bar actually. You kind of get away with it inside.’ (No.11, Male, 29 years).

However, another interviewee modified his e-cigarette use in response to negative reactions. He reflected on bystanders’ reactions to him using e-cigarettes inside the bus:

When asked if bystanders told him it’s ‘a non-smoking bus’, he remarked: ‘No, nobody said nothing.’ (No.7, Male, 24 years). This suggests that the negative facial expressions from other passengers signaled a social cue that using e-cigarettes, like smoking cigarettes, is unacceptable and prohibited inside the bus. Another interviewee reported that she was very aware of her e-cigarette use inside the train. Recalling how her friend initially thought she was about to smoke a cigarette, she explained that she anticipated bystanders’ possible negative reaction to her e-cigarette use:

She went on to describe how being able to satisfy her desire to smoke a cigarette at that moment, motivated her e-cigarette use inside the train:

After initiating e-cigarettes, he reported in his second interview that he tested the social and spatial boundaries of e-cigarette use inside the train but not inside other smoke-free places that he frequents, like church and restaurants:

Although bystanders did not react negatively or positively to his e-cigarette use inside the train, he described a complex decisional balance influenced by fear, perceived rights as a smoker, and a lack of comfort using e-cigarettes that prevented him from ‘testing’ other smoke-free places.

However, one participant described himself as a ‘trendsetter’, and articulated positive reactions from bystanders and social acceptance: ‘I feel like everybody wanted to smoke what I was smoking. Everybody, they seen me with it [e-cigarette] and they wanted to have it. I felt like I was a trendsetter or something.’ (No.18, Male, 18 years). Additionally, in his third interview, he reported that he used e-cigarettes inside a restaurant and recalled the initial reaction from bystanders, including the security guard:

His remark that ‘this is the e-cigarette’, and the security guard’s consensus, suggests that e-cigarette use inside the restaurant is permissible because e-cigarettes are not cigarettes.

Strengths and limitations

By employing repeated one-on-one interviews with adult daily cigarette smokers transitioning to e-cigarettes, our findings fill an existing gap in the literature and offer new explanations of why, where, and how e-cigarette use in smoke-free places/situations occurs. While the present study is based on a small and non-random sample that is justifiable for qualitative research²⁴, an important caveat is the limited generalizability of the study’s findings beyond its 20 interviewees. The study does, however, offer new insights and raise important questions for further investigation. Providing adult smokers e-cigarettes and asking them to report back on their use via repeated individual interviews provides a novel way to collect qualitative data. Studies of the differences in reporting between naïve and established e-cigarette users are needed. Comparisons with adult daily e-cigarette-only users could also extend understanding of how users incorporate these devices into their daily lives. Further, comparisons to dual cigarette and e-cigarette users in rural areas could validate or invalidate the influence of the urban-suburban environment.