Vape shops: who uses them and what do they do?

Electronic cigarettes (e-cigarettes) provide a less hazardous alternative to smoked tobacco for smokers, and can aid smoking cessation [1‐6]. E-cigarettes are increasingly widely used, with 20% of smokers and recent ex-smokers in England reporting use in the first quarter of 2017, compared with 3% in 2011 [7]. E-cigarettes are now the most commonly used cessation aid in England; an estimated 34% of adults who quit or made a quit attempt in the last year reported using e-cigarettes in their most recent quit attempt, compared with 21% using over-the-counter nicotine replacement therapy and less than 3% receiving behavioural support [7]. The number of specialist e-cigarette shops has also increased, with recent estimates suggesting that the UK has 1700 ‘vape shops’ [8‐10]. The high street locations of vape shops make them an easily accessible option for smokers, and they are currently the most popular source for purchasing e-cigarettes in England [7].

Smokers who use vape shops are likely to be interested in temporary abstinence, cutting down or quitting smoking. Since vape shop staff have a potential major role in capitalising on opportunities to promote smoking cessation through their engagement with customers, it is important to understand the products they sell and marketing techniques they employ, and the extent to which they provide information or encouragement to smokers to quit all tobacco use. To date, the available evidence is limited to studies of vape shops in the USA, and one qualitative study in the UK [11‐26]. While anecdotal reports suggest that some UK shops offer services such as smoking cessation advice and receive referrals from local health services, there are no quantitative studies of these or other vape shop functions and activities in the UK. We now report cross-sectional surveys of the products and services, including smoking cessation advice, offered in vape shops in the East Midlands region of the UK, and of the patterns of tobacco and e-cigarette use and sociodemographic characteristics of their customers.

This study found that vape shops cater for customers seeking a wide range of nicotine content, flavours and price points, and offer a variety of promotions. Most vape shop customers were current vapers who had quit smoking, and were using an e-cigarette to either quit or stay quit. A very small minority were vapers who had never smoked. The majority of customers had reduced the nicotine content of their e-liquid since taking up vaping. Shop staff reported that most customers ask for advice about quitting smoking, but that most of the information they provided was about the products they sell. There were mixed views among both staff and customers as to whether it would be appropriate to deliver smoking cessation advice in-store; however there was broad consensus that if such support were to be delivered, support from a trained member of existing staff would be preferred.

Our study has a number of strengths and limitations. Most existing vape shop studies have used qualitative techniques; by using a survey we were able to quantify key characteristics in our population, such as dual use, albeit that we were not able to analyse smoking/vaping trajectories over time. Nevertheless, some aspects, such as understanding the type and accuracy of advice given to customers, would have benefitted from qualitative interviews with shop staff.

While we only used one directory to identify shops, the use of a large vape shop-specific directory rather than a generic business directory (e.g. Yell) means that we are likely to have identified the majority of shops in our study area. Recruitment to the study was more challenging than anticipated; we approached 65 shops, but only 41 agreed to take part. While the sample size of both surveys is therefore relatively small, and prevents us from reliably analysing subgroups (e.g. new vs. long-term vapers), our findings provide an initial insight into who accesses vape shops and why, the products and services offered and the potential for capitalising on opportunities to promote smoking cessation in the vape shop setting. We used a systematic approach to identify vape shops in the East Midlands region, and a sampling strategy which maximises the representativeness of our sample. The study was conducted in a limited geographic region; however we sampled shops in both urban and rural areas to maximise the representativeness of our sample. Our study was conducted prior to the implementation of the EU Tobacco Products Directive, which imposed limits on nicotine strength (20 mg/ml) and e-liquid bottle sizes (10 ml) in the EU [28]; the typical nicotine concentration and bottles sizes will therefore have changed in UK vape shops since our study was conducted.

Our pragmatic approach to data collection means that our customer sample is not random. Some respondents, particularly customers, often lacked the time to fully complete the survey resulting in some missing data. Furthermore, we found that the vape shop setting made it impractical to collect carbon monoxide readings to confirm smoking status, and this measure is therefore based on self-report. There is a risk of social desirability bias whereby respondents are more likely say they have quit smoking cigarettes because they are in a vape shop; however, in existing research biochemical validation found that the vast majority of self-reported quitters in vape shops had indeed quit [25]. Our combination of face-to-face interviews and allowing customers to complete questionnaire in their own time is likely to have maximised the amount and quality of data collected.

Our finding that the majority of vape shop customers were ex-smokers and used e-cigarettes to stop smoking or stay quit conflicts somewhat with population-level data suggesting that around half of adults who use e-cigarettes are dual users [7, 29]. It seems likely that vapers who use specialist vape shops are not representative of vapers in general, and may represent a group more committed to vaping (and hence more likely to have quit smoking) than casual purchasers of e-cigarettes from convenience stores and supermarkets. While we are unable to draw any causal links between this population’s e-cigarette use and quitting smoking, our findings underline that many vapers are successful quitters. Furthermore, our study found that the majority of ex-smokers had quit smoking more than a year ago, suggesting that e-cigarettes may help in sustained as well as in initial cessation. While there is limited evidence as to the effectiveness of e-cigarettes for quitting when bought in vape shops, one pilot study found that at 12 month follow-up, 40% of smokers making their first purchase at a vape shop had quit smoking [16].

Around two thirds of vapers in our sample reported having cut down their nicotine concentration in their e-liquid since taking up smoking; this is consistent with a previous study conducted in the US [20]. This finding may reflect improvements in the ability of e-cigarette devices to deliver nicotine [25]; however, the level by which customers report cutting down (an average of 13 mg/ml among those reducing) suggests that e-cigarettes may enable a two-stage quitting process whereby smokers reduce or overcome their nicotine addiction before attempting to end the habitual behaviours involved and associated with smoking. However, while the majority of our sample used a relatively low nicotine concentration when they started vaping, over a quarter reported using an e-liquid containing a level of nicotine exceeding restrictions imposed by the new EU Tobacco Products Directive (20 mg/ml) [28]. This raises concerns that at least some potential vapers will be put off by fears that e-cigarettes will, at least at the outset, provide insufficient levels of nicotine.

Many customer survey respondents reported cost as a factor which influenced their decision to use e-cigarettes, and most reported a weekly spend of less than £10, i.e. less than the cost of a single pack of 20 premium cigarettes. Existing evidence suggests that 1 ml of e-liquid is consumed over a length of time equal to that which in which a typical smoker consumes 5.63 combustible cigarettes [30]. Based on this assumption, a starter kit costing £20 containing 10 ml of e-liquid would provide the equivalent of 56 cigarettes (2.8 packs of 20). The weighted average price for 20 cigarettes in the UK is currently £7.8 [31] – this suggests that, in the UK, where the price of combustible tobacco is high, the start-up cost of vaping may be similar to the cost of (licit) tobacco; the cost of ongoing e-cigarette use is likely to be lower. Furthermore, we found that shops frequently run promotions, which is likely to help keep the cost down. Smoking imposes a substantial financial burden on smokers, a high proportion of whom are already living on low incomes [32]. The lower cost of e-cigarettes and the price-based marketing approaches used by vape shop customers are therefore encouraging, as they highlight the potential of e-cigarettes as not only a less harmful but also a cheaper alternative to smoking. Existing evidence suggests that in England, vapers are more likely to be from high socioeconomic groups [7]. Ensuring that deprived smokers are informed of the financial benefits, as well as potential health benefits of switching to e-cigarettes may be a way of encouraging use in this population.

Our findings support existing evidence that e-cigarette users are more likely to have accurate perceptions of harm of vaping than the general population or smokers who do not vape; nearly all our customers respondents (82%) believed vaping to be less harmful than tobacco smoking [29]. Given that role that vape shop staff are likely to play in influencing vapers’ and potential vapers’ perceptions of harm and other aspects of vaping (such as effectiveness for smoking cessation), it is essential that they look to accurate and up-to-date sources of information about e-cigarettes. However, previous research suggests that information conveyed to vape shop customers may be incomplete or misinterpreted [13]. Our findings that staff access information in a wide range of ways, including online and based on personal experience, suggests there is a risk that staff may provide inaccurate or biased information. Future research should consider ways to ensure that vape shop customers, particularly those considering vaping for the first time, are given up-to-date evidence-based information.

There were mixed views about whether delivering formal smoking cessation advice in shops was a good idea. This may reflect existing evidence which suggests that to some e-cigarette users pleasure and enjoyment are central to the vaping experience, while others regard e-cigarettes as a medical treatment for nicotine addiction, with enjoyment and culture playing much less of a role [33]. A recent vape shop study by Ward et al. identified a divide between groups of e-cigarette users, with some liking the non-medicalised environment of vape shops, but others, who perceive e-cigarettes as a medical treatment, sometimes being intimidated by the vape shop setting. It has been suggested that providing ‘recreational’ and medical pathways to e-cigarette use may maximise the potential for harm reduction [33, 34], and Ward et al. suggest that ‘informal co-working between shops and stop smoking services’ could encourage smokers who are unsure about e-cigarettes [26]. Our mixed findings indicate that achieving this successfully within the vape shop setting might be challenging, given the need to appeal to those seeking a ‘medical’ solution, without putting off vapers who are not seeking ‘treatment’. However, it seems likely that some smokers may feel more confident about accessing vape shops and using e-cigarettes if they know that evidence-based support is available, and therefore that providing support may enhance vape shop profitability.

Among staff and customers who were supportive of an in-store smoking cessation intervention, most felt that the best way to deliver this type of service would be via a trained member of existing staff, although our data did not provide sufficient granularity to gain a comprehensive understanding of the type of advice and mode of delivery that might be appropriate and acceptable. Whether offering help to smokers to transition more effectively from tobacco to electronic cigarettes represents a commercial opportunity to vape shops, by helping to generate new customers; and whether this same commercial interest might then inhibit the promotion of complete cessation of vaping, remains to be seen.

The majority of vape shop customers are vapers who have quit smoking. Vape shop staff play a central role in providing customers with product information, and many provide smoking cessation advice. There is a need for clear and easily accessible information on the health effects and effectiveness of e-cigarettes for smoking cessation, to ensure that vape shop staff provide customers with accurate information on their products. Further research is needed to investigate the potential for smoking cessation interventions in vape shops, including the extent to which this type of intervention would appeal to non-vapers and how and by whom it would best be delivered.