Addicted to smoking or addicted to nicotine? A focus group study on perceptions of nicotine and addiction among US adult current smokers, former smokers, non‐smokers and dual users of cigarettes and e‐cigarettes

Abstract

Background and Aims In 2017, the US Food and Drug Administration (FDA) proposed to reduce nicotine in cigarettes to minimally or non‐addictive levels. This study qualitatively explored perceptions of nicotine and addiction, both independently and in response to messages communicating about nicotine reduction. Design Qualitative study using focus groups. Participants described their perceptions of nicotine and addiction and their responses to messages about the nicotine reduction. Setting Atlanta, GA and San Francisco, CA, USA. Semi‐structured focus groups were conducted virtually in Spring 2020. Participants Exclusive smokers (n = 27), dual users (of cigarettes and electronic cigarettes) (n = 25), former smokers (n = 32) and young adult non‐smokers (n = 31). Measurement Inductive thematic analysis of transcripts was conducted, and results were compared across smoking status groups. Findings Participants across all smoking status groups associated nicotine with tobacco products, but consistently misperceived that nicotine caused disease. Perceptions of addiction were largely negative and varied by smoking status. Experienced smokers (exclusive smokers, former smokers and dual users) differentiated tobacco use from other addictions and minimized their own experiences of addiction. Perceptions of addiction across experienced smokers included not only the chemical properties of nicotine, but also the behavioral aspects of tobacco use, including oral fixation, having a smoking routine and response to internal and external cues. In response to messages, many believed that removing the nicotine would not make cigarettes less addictive because of the multi‐factorial nature of smoking addiction that includes non‐pharmacological cues. Conclusions Perceptions of nicotine and addiction among non‐smokers, former smokers, exclusive smokers and dual users of cigarettes and e‐cigarettes vary based on smoking status, but there is a common tendency to believe that nicotine is addictive, that addiction results from more than just nicotine, and that very low nicotine cigarettes will not necessarily reduce the addictiveness of cigarettes.

Commentary on Loud et al.: Reconsidering nicotine dependence in adults

“…Language use positioning people with 'an addiction' has the consequential impact of devaluing the views, behaviour and social standing of that person. Loud et al [4] demonstrate how non-smokers saw addiction as 'a choice', also perpetuating stigma by locating blame for addictive behaviour. Use of free association is referred to as accessing the 'experiential mode' of understanding, bypassing the 'logical' or 'analytical' mode.…”

“…As beliefs can be powerfully held and maintained, the qualitative approach utilized by Loud et al . [4] is critical in understanding perceptions that ultimately influence health behaviour. Participants in their study ‘consistently misperceived that nicotine caused disease’.…”

“…Loud et al . [4] demonstrate how non‐smokers saw addiction as ‘a choice’, also perpetuating stigma by locating blame for addictive behaviour. Use of free association is referred to as accessing the ‘experiential mode’ of understanding, bypassing the ‘logical’ or ‘analytical’ mode.…”

“…It is this experiential mode that ultimately drives behaviour and is vital for us to understand. Loud et al [4] also find that both current and non-smokers expressed the view that switching to other nicotine products would be simply 'exchanging one addiction for another', without wider consideration of harm to health of different routes of nicotine administration. This is concerning, as it demonstrates a preoccupation with the concept of 'addiction' that may potentially negatively impact health behaviour through discouraging switching to reduced-harm nicotine-containing products.…”

“…It is essential when attempting to understand views of nicotine and addiction to access the lay narratives of people who smoke and ex-smokers themselves, alongside quantitative research. As beliefs can be powerfully held and maintained, the qualitative approach utilized by Loud et al [4] is critical in understanding perceptions that ultimately influence health behaviour. Participants in their study 'consistently misperceived that nicotine caused disease'.…”