Research Article
E-Cigarette Design Preference and Smoking Cessation: A U.S. Population Study

https://doi.org/10.1016/j.amepre.2016.02.002Get rights and content

Introduction

Electronic cigarette (e-cigarette) designs may be described as “closed” or “open.” Closed systems are disposable or reloadable with prefilled cartridges (cigalikes). Open systems feature a prominent chamber (tank), refillable with e-liquid. This study examined user design preference and its association with smoking cessation.

Methods

A probability sample of current e-cigarette users (n=923) among adult ever smokers (n=6,560) in the U.S. was surveyed online between February 28 and March 31, 2014, and analyzed in September 2014. Photos of e-cigarette devices were presented alongside survey questions to facilitate respondents’ understanding of the questions.

Results

Most e-cigarette users were exclusive users of one design: 51.4% used only closed systems and 41.1% used only open systems, with 7.4% using both. Former smokers were more likely to use open systems than current smokers (53.8% vs 35.2%, p=0.002). Current smokers who attempted to quit in the last 12 months were more likely to use open systems than those who did not (41.4% vs 27.7%, p=0.029). Open system users were more likely than closed system users to use e-cigarettes daily (50.2% vs 22.9%, p<0.0001). Open system users were less likely to report their devices resembled (3.1% vs 73.0%, p<0.0001) or tasted like (29.1% vs 53.3%, p<0.0001) a cigarette but were more likely to report that their devices satisfied cravings than closed system users (82.8% vs 67.2%, p=0.001).

Conclusions

Preference of e-cigarette design is associated with smoking cessation. A device’s ability to deliver more nicotine and its flexibility in use might contribute to users’ success in quitting smoking.

Introduction

The design of electronic cigarettes (e-cigarettes) is evolving even as their use is increasing.1, 2, 3 The battery-powered devices that vaporize a nicotine-containing solution for inhalation first arrived on the U.S. market in 2007.4 In 2012, large U.S. tobacco companies began acquiring and designing their own e-cigarette devices.5 In 2014, the U.S. Food and Drug Administration (FDA) issued the “deeming rule” indicating its plan to regulate e-cigarettes.6 Currently, e-cigarettes are not yet regulated by the FDA. This study examines user preferences regarding e-cigarette designs and their association with smoking cessation in this unregulated environment.

E-cigarettes can generally be grouped into two models: “closed systems” and “open systems.” Older generation e-cigarettes were mostly closed systems that mimicked regular cigarettes in size, weight, and appearance and were either disposable or reloadable with cartridges of pre-filled solution.7 These are also known as “cigalikes.”8 Closed systems do not allow users to fill their devices with third-party “e-liquids” (nicotine-containing solutions). Instead, these devices typically use their own branded, pre-filled cartridges with limited choices of flavors and nicotine concentrations. Closed systems are not customizable. Modification of hardware is considered “tampering,” effectively voiding the product warranty.9

Open systems, by contrast, invite a do-it-yourself ethos. These devices, also referred to as “tanks,” “e-vapors,” and “mods,” are characterized by hardware that feature a refillable chamber that users can open and fill with their choice of e-liquid. In contrast to closed systems, these devices allow users to select from a greater range of nicotine concentrations among a wider variety of flavors.10 Users can also purchase basic ingredients and mix their own customized e-liquid.10

Open systems also allow users to modify their devices. Specialized mouthpieces and variable voltage options are some examples of possible enhancements.11 Visually and tactilely, these devices are different from closed systems; they are usually larger and heavier, resembling a fountain pen or small flashlight.

Open systems are generally capable of delivering higher levels of nicotine than closed systems.12 Increased flexibility such as variable voltage also allows users to adjust the temperature for heating e-liquid, which can increase nicotine yield and puff volume.11, 13 With practice, users can achieve higher nicotine intake from their devices.14

The present study examines whether e-cigarette design preference among current users is associated with success in quitting smoking. Open system devices are reportedly more effective in reducing withdrawal symptoms.12 Online surveys found that an overwhelming proportion of e-cigarette users preferred open systems.15, 16 A survey in the United Kingdom has also found that those who used open systems on a daily basis were more likely to quit.17 By contrast, a case-control study showed that closed system users were more likely to continue smoking while using e-cigarettes.18 No study, to the authors’ knowledge, has examined the e-cigarette user experience and users’ success rate using a representative sample of the general population. This study is based on a nationally representative sample of U.S. adults.

Section snippets

Study Sample

The University of California, San Diego designed an online survey and commissioned GfK (Menlo Park, CA) to administer it to a probability sample of the U.S. population (KnowledgePanel®). The KnowledgePanel is an ongoing probability panel that relies on address-based sampling from a sample frame of residential addresses that covers about 97% of U.S. households, including those with unlisted phone numbers, and those without landlines and Internet access.19 Households without Internet were

Results

Most e-cigarette users used only one type of device. As shown in Table 1, 41.1% used open systems exclusively and 51.4% used closed systems exclusively. Among all current and former smokers who currently use e-cigarettes, 7.4% used both closed and open system devices.

Table 1 also shows the demographics of users. Among exclusive users, there was no significant gender difference between closed or open system users. Open system users were more likely to be younger (aged <45 years). There were no

Discussion

This study found that in 2014, more e-cigarette users were using closed than open systems in a representative sample of smokers in the U.S. However, those who succeeded in quitting smoking were more likely to use open systems. Further, among those who still smoked cigarettes, those who tried to quit in the last 12 months were also more likely to use open systems than those who had not tried to quit.

Closed system devices were introduced to the U.S. market at an earlier point in time than open

Conclusions

This study used a cross-sectional representative sample of the U.S. population to show that smokers who were attempting to or who successfully quit smoking were more likely to use open than closed system e-cigarette designs. Before the FDA implements regulatory policies,6 e-cigarette designs will continue to evolve in their absence. At this critical time as policies to regulate e-cigarettes are being formulated, regulators need to take into account the design of devices that can facilitate

Acknowledgements

We wish to thank Anthony Gamst, Sharon Cummins, and Gary Tedeschi for helpful comments on earlier drafts of the paper and Lu Yin for statistical assistance.

This study was supported by the National Cancer Institute of the NIH under the State and Community Tobacco Control Initiative, Award Number U01CA154280. The content is solely the responsibility of the authors and does not necessarily represent the official views of NIH. The study sponsor had no role in study design; data collection,

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