Whether e-cigarettes can help address health inequalities will depend on take-up in deprived communities – but cost and ‘faff’ are discouraging deprived smokers from switching, according to new research.
The study involved community-based research in the North East of England with smokers and quitters over three years from 2012 to 2015. Research participants bought both tobacco and electronic cigarettes largely through informal outlets and personal networks – but for the very poorest, cost was a barrier to any e-cigarette use. Although £10 would buy a starter tank and e-liquid, smokers could get a week’s worth of illicit rolling tobacco for the same money. The poorest could not risk such a large outlay on something that might not work.
Figure 1: People bought from informal outlets
Even those who could afford better tended to buy cheap e-cigarettes (and cheap tobacco if they were still smoking) because addiction was a problem for their moral identity, as was excessive expenditure on the self. Older people were particularly likely to be put off by the association of the e-cigarette with pleasure or play, and avoided aspects of e-cigarette use which they associated with frivolity or self-indulgence: sweet flavours, expensive parts, vaping shops, culture and language.
Users struggled with the faff factor
Users struggled with the time, effort and expense involved in finding the ‘right’ e-cigarette and the frequency of product failure i.e. cheaper tank models splitting, leaking, or bubbling if over-tightened or dropped, and problems with batteries running out or failing to charge. Unless users were highly motivated to quit, smoking was easier and cheaper taking into account the cost of e-cigarette replacement and the availability of illicit tobacco.
This practical problem was also a gender issue. The energy, time and money needed to switch successfully to e-cigarettes were often lacking for older women heavily invested in family care, whose personal health was relatively low in their hierarchy of concerns. Mature women in the study had a relational sense of identity in which care of the self was at the bottom of a hierarchy of concerns. For these women, their own health simply did not seem important enough, in comparison with the many tasks they did for others, for them to put in the effort needed to quit. As a result, whilst they might try an e-cigarette, they quickly became impatient with aspects in which it compared poorly with the ever-reliable, endlessly replaceable cigarette.
Figures currently show slightly more women than men using e-cigarettes overall. Women are more likely to use disposable or first-generation ‘cigalikes’, but since second-generation devices deliver nicotine more effectively and are more satisfying to users, there is a risk that using less effective models may translate into fewer women ceasing to smoke. Gender is not discussed in the most recent UK e-cigarette evidence review; further research will be needed to establish whether there is a gender differential in the use of e-cigarettes to quit smoking successfully.
Young men bought into vaping culture
Smoking cessation conflicted with a local ethic of working-class hedonism which encouraged sociable smoking and drinking, particularly among younger men. This meant that to abstain or quit smoking was to risk being seen as pretentious or insufficiently masculine. However, using an e-cigarette overcame this problem, not least because an interest in gadgets and technology was a legitimate male trait. The e-cigarette was therefore a viable masculine accessory in combining hedonism with technology.
Local masculinity was performed differently in mature adulthood, at which point smoking cessation could function as part of a narrative of family responsibility or indeed of mastery; older men positioned their e-cigarette use within this functional narrative. Normative masculinity also required that one should give up smoking if suffering serious ill-health such as cancer, stroke or heart attack; not to do so in such circumstances implied weakness or a lack of self-control. Some men with serious health problems who were unable to quit smoking remained dual users of tobacco and e-cigarettes, but deployed e-cigarettes as a badge of moral intent.
The success of the e-cigarette in addressing health inequalities will partly depend on whether it enables users to overcome locally normative barriers to cessation. These findings suggest that it does have some potential to do this, at least in relation to men. However, the e-cigarette is constantly changing and increasingly regulated; should it become a more medicalized product, it might lose its attractiveness as a masculine accessory. On the other hand, if more reliable and effective models start to dominate the market, this will diminish the trial and error process which discourages older women users in particular.
Whilst the findings of this study cannot be generalised to deprived areas across the UK or further afield, local meanings of smoking and cessation in relation to gender and age are crucial to e-cigarette take-up, as are place-based smoking and cessation practices more generally. Most importantly, we need to appreciate that local norms can sometimes make giving up tobacco or taking up e-cigarettes more of a risk to moral identity than carrying on smoking.
The full article is open access and available here:
Thirlway, Frances (2016). Everyday tactics in local moral worlds: e-cigarette practices in a working-class area of the UK. Social Science & Medicine 170: 106-113.
About the author
Frances Thirlway is a Research Associate at Durham University and an associate member of FUSE – the UKCRC Centre for Translational Research in Public Health. Her research interests are in health, class and culture, with a particular interest in smoking cessation (including e-cigarette use) in relation to health inequalities in the north of England and in Scotland. Follow her @fthirlway
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