According to the Centers for Disease Control and Prevention, about 6.5 percent of U.S. adults use e-cigarettes, and roughly 15% to 26% say they want to quit. Psychologists at Texas A&M University are now asking: How do they succeed?
Traditional smoking has been on a significant decline during the past few decades, seen as a remnant from a bygone era that has stolen the health and quality of life from Baby Boomers and some of Generation X. The smoking epidemic seemed like it was finally going to be a thing of the past until e-cigarettes hit the scene, prompting a new generation to start the cycle again.
E-cigarettes, despite their emergence as a “better” alternative to traditional tobacco smoking, pose the same risks as their old-fashioned counterparts thanks to their nicotine and heavy metal content. They are far more expensive than traditional tobacco smoking, easy to contaminate (often with illicit substances) and the disposable pods create an excessive amount of waste. But they are “cool.” Many teens and young adults quickly got hooked on the habit. With rising costs, stricter school discipline and growing evidence of health risks, some users are starting the difficult journey to quit.
Drs. Sherecce Fields and Rachel Smallman have dedicated multiple collaborative studies to understanding the psychology of risky health behaviors. Their most recent research paper explores the understudied territory of e-cigarettes and how protective behavioral strategies, such as keeping e-cigarettes out of reach or limiting daily use, affect behavior. They also tested how strategies that work for traditional tobacco smokers or alcoholics may be altered for e-cigarette users.
“Vaping is an epidemic right now,” Fields said. “And it’s not just in the U.S. — it’s all over the world. This research is personal to me because it affects schools so much. For example, my son’s school here in Texas have locked the doors to the bathrooms so students won’t be in there vaping and skipping class.”
Fields, a professor and APS Fellow with a Ph.D. in clinical psychology, studies health psychology and behavioral medicine. Smallman, an associate professor, is an experimental social psychologist who studies counterfactual thinking, reflecting on how events in the past could have happened differently, and how it can improve future behavior.
“For this particular paper, one of our graduate students contacted Denise D. Tran, a postdoctoral student at the time, who had developed a protective behavioral strategy scale for vaping,” Smallman said. “The strategies we used in the past were related to alcohol consumption, so this was an opportunity to test out a new scale.”
Tran’s scale identifies three areas of protective behaviors:
1) Manner of use strategies like limiting frequency and quantity of vaping
2) Avoiding use by creating obstacles to using
3) Commitment to quitting and using support systems
Developing and testing these behavioral strategies has proven to be an essential area of study in learning how to best assist e-cigarette users. The previous strategies created for alcohol or traditional tobacco smokers do not necessarily apply because of the societal perceptions around vaping and because the negative health effects are less visible.
“With vaping, we can’t focus on traditional consequences like the nasty tobacco smell or yellow teeth,” Fields said. “When we used the same intervention with cigarette smokers, they responded negatively. For many, smoking is part of their identity, which makes it harder to challenge. Vaping carries much less stigma, so users are less likely to have deeply ingrained beliefs that ‘everybody is against me.’”
One of the unique aspects of incorporating protective behavioral strategies into therapeutic treatments for smoking cessation is the individual’s ability to choose what strategies they want to use. They get to choose what works best for them, making every treatment personalized to their needs. A person may like to smoke immediately after eating, so an effective strategy for them would be to chew gum after a meal instead of reaching for a vape. These strategies can also be used by a variety of healthcare professionals, ensuring ease of access to care.
These strategies work nicely because they are concrete things that are specific that you can figure out how to implement, Smallman said. “It's not like everybody must do the exact same thing, and they can be implemented by talking with psychologists, clinicians or nurses but also community health educators. It doesn’t require a Ph.D.-level individual to perform this intervention.”
Like other vices, an individual’s vaping habits and the reasons why they vape can be highly specific. Where they are categorized on their dependency and reasons for usage is why a scale for protective behavioral strategies is so important. According to Fields, people fall into the classification of experimenters, triers and users, with each group’s dependency and withdrawal symptoms differing over time due to built-up tolerance.
Protective behavioral strategies across all types of dependencies and behaviors still share one common goal: helping people control their behavior to live healthier lives. Instead of vague, general advice or wishful thinking, these strategies help people take their health back into their hands.
“PBS originated from things like alcohol, cannabis, vaping and eating. All of these are health-oriented behaviors that people want to fix, but don't know the specific steps on how to do that,” Smallman said. “These give clear cut steps that they can use and they're fairly accessible.”
A Culture of Collaboration
Fields’s previous research explores other risky behavior and detrimental health habits, including risky sexual encounters, eating addictions, problematic social media use and alcohol consumption. Throughout, she observed co-occurring risky habits, identifying commonalities that cause people to be a detriment to their own health.
“My big construct is delayed discounting, choosing an immediate reward versus a long-term, more beneficial one,” Fields said. “People are doing things that make them feel good; they are not thinking about long-term consequences. The key takeaway of our research is to help people think more about their future, more beneficial goals rather than immediate gratification.”
Fields and Smallman are frequent, compatible collaborators. Fields brings expertise in behavioral decision-making and impulsivity. Smallman contributes knowledge in counterfactual, or “what might have been,” thinking and how other social psychological theories can be applied to health-related behaviors.
Their success led them to create the Innovative Strategies in Cognitive And Regulatory Processes to Enhance Digital and Behavioral Health (iCARE) Collaboratory at Texas A&M University, the lab in which they conducted this research.
“Working with Rachel is exciting because we are developing our own intervention,” Fields said. “We know the basic foundations of why people smoke and what keeps them smoking. Now we are challenging some of those ideas to help people quit.”
The duo has no plans to slow down and are continuing their work at the collaboratory to further understand a variety of risky behaviors and health habits. They are leading a team of students to explore how findings of this study may apply to other addictions or afflictions.
“Some of our interventions are helping people with Type 2 diabetes control glucose management,” Smallman said. “Some of our students are exploring interventions for binge-eating behavior, while others are focused on decreasing cannabis use, and we continue to examine the alcohol-related consequences of unsafe romantic interactions.”
Despite their breakthroughs, research alone cannot fully solve the vaping crisis. Laws, marketing practices, and social perceptions must change to encourage more people to quit e-cigarettes. Fields expressed that an important part of preventing people from starting a vaping habit, as well as encouraging them to quit, comes down to changing the way society portrays and discusses the topic.
“The most significant issue we face is how e-cigarettes are advertised and marketed to adolescents and emerging adults,” Fields said. “How we communicate to young people about their ability to quit is essential: ‘You have the strength. You have the ability. You have the skills. Maybe you just need a little help.’ Even if you quit, and even if you have a relapse, that doesn't mean that is the end of the line. Often it takes people multiple times to quit before they succeed.”