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Abstract
Introduction In 2017, the New Zealand Government signalled its intent to legalise the widespread sale of Electronic Nicotine Delivery Systems (ENDS), which many New Zealand retailers have actually sold for several years. Although ENDS uptake may reduce the harm smokers face, it requires them to adopt an entirely new practice; we therefore explored how effectively existing non-specialist tobacco retailers could advise and support potential quitters.
Methods Using in-depth interviews with 18 tobacco retailers (prior to legislative change), we explored knowledge of ENDS, attitudes towards selling ENDS and supporting customers’ cessation attempts, perceptions of ENDS’ risks and benefits, and views on the proposed legislation.
Results Participants generally had poor knowledge of ENDS products and provided either no advice or gave incorrect information to customers. They believed that the main benefit consumers would realise from using ENDS rather than tobacco would be cost savings; relatively, few saw ENDS as smoking cessation devices. Those who stocked ENDS did so despite reporting very low customer demand, and saw tobacco as more important to their business than ENDS, citing higher repeat business, ancillary sales and rebates. Participants typically supported liberalising ENDS availability, though several expressed concerns about potential youth uptake.
Conclusions Tobacco retailers’ limited understanding of ENDS, and the higher value they placed on tobacco, suggests they may have little capacity or inclination to support ENDS users to quit smoking. Licensing schemes for both ENDS and smoked tobacco could simultaneously reduce supply of smoked tobacco while requiring ENDS retailers to meet minimum knowledge standards.
- tobacco control
- retail
- regulation
- public policy
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Introduction
Electronic Nicotine Delivery Systems (ENDS) products sold in New Zealand (NZ) have evolved rapidly in recent years, as has the ENDS supply chain. At the time of the research, NZ law did not allow sale of nicotine-containing e-cigarettes and e-liquids, although sales via internet-based outlets and at brick-and-mortar tobacconists, specialist ‘vape shops’ and convenience retailers had occurred for several years.1 This anomalous situation, together with a recent court decision, led the NZ Associate Minister of Health responsible for tobacco to propose amending existing legislation to allow ENDS sales (online supplementary file 1 outlines the history of NZ ENDS regulation).2
Supplemental material
Considering these restrictions, ENDS use in NZ has been reasonably high, with around 17% of people aged 15 years and older having ever used ENDS; 6% on a daily basis and 3% at least weekly.3 While regular ENDS users tend to be adult quitters,4 the high prevalence of ever-use among 15- to 24-year olds (30%) has prompted concern, as has the rapid increase in ever-use among NZ 14- to 15-year olds, from 7% in 2012 to 33% in 2018.3 5 6 As the NZ Government has proposed allowing sales of vaping products containing nicotine wherever tobacco is sold, it is crucial to consider the potential impact of greater ENDS availability.
The Government’s proposal to liberalise ENDS availability could theoretically improve public health and reduce health inequities, if existing smokers switch completely to ENDS and stop smoking altogether.7 Yet, as the Government acknowledges, ENDS’ contribution to population health gains depends on ‘the extent to which they can act as a route out of smoking for NZ’s 550 000 daily smokers’.8 Most NZ ENDS users report concurrent smoked tobacco use (64%),9 and users may require better information and support to navigate transitions from dual use to exclusive ENDS use.10 11 Retailers with sound knowledge of the products they sell and how switching occurs could play a crucial role in determining whether these population health gains are realised. Specialist vape shops, typically staffed by people who have themselves transitioned from smoking to using an ENDS device, may provide this advice and guidance.12 13 However, it is unclear how effectively non-specialist retailers support transitions from smoking to vaping. To inform proposed legislative change, we examined the following research questions:
RQ1: What knowledge do non-specialist tobacco retailers have of ENDS products, and how effectively could they assist smokers wishing to use ENDS in a cessation attempt?
RQ2: What are non-specialist tobacco retailers’ views on the Government’s plans to liberalise ENDS sales, and on selling ENDS as a potential alternative to combustible tobacco?
Methods
Sample and procedure
We developed a semistructured, in-depth interview guide that outlined specific discussion topics but used flexible wording and question sequence to maintain a natural and conversational interview (see online supplementary file 2). Drawing from a national database of 5500 known tobacco retailers compiled in previous research,14 we identified retail outlets using a purposive sampling strategy stratified by area-level socioeconomic status,15 urban/rural location and outlet type. We drew an equal number of retailers from the Otago and Wellington regions to ensure a varied representation of tobacco retailers in NZ. We recruited 18 participants, after which saturation (defined as no new idea elements in two consecutive interviews) was achieved and data collection stopped (figure 1 outlines how the final sample was achieved).
Supplemental material
Response Flowchart.
LR and LT conducted the interviews, which lasted an average of 43 min, between November 2017 and March 2018. The interviewers visited potential participants, told them the study aims, gave them an information sheet and set an interview time with those who consented and met eligibility criteria (eg, English language comprehension was sufficient to enable informed consent, and agreed to be audio-recorded). All participants gave written informed consent before the interview commenced and were offered a NZ$40 gift voucher to reimburse any expenses they incurred by participating in the study. The study was reviewed and approved by a delegated authority of the University of Otago Human Ethics Committee.
Data analysis
The interviews were transcribed verbatim and checked by LR and JB; LR drafted a coding structure using the interview guide as an initial framework, which she, JH, LM and JB reviewed and agreed. We analysed the data using qualitative descriptive analysis, provides ‘rich, straight descriptions’ and elicits information for practical applications rather than to inform theory development.16 JB, JH and LM coded five transcripts independently, compared and refined initial categories, discussed key findings and agreed on policy implications. JB coded the remaining transcripts in consultation with LR, LM and JH. Online supplementary file 3 contains a summary code book illustrating theme development.
Supplemental material
Results
Participant characteristics
The sample of 18 participants comprised 12 men and 6 women, aged 25–59 years. Seven participants were Indian, six were NZ European, four were Chinese and one identified as both NZ European and Māori. Nine of the retail outlets sampled were convenience stores, eight were supermarkets and one was a service station. Table 1 contains details of store and participant characteristics; participants are referred to as (P(n)) with Y indicating they sell ENDS and N indicating they do not.
Participant characteristics
Knowledge of ENDS products and how to use them
Participants had little knowledge of ENDS or how to use the devices they sold. P1(Y) stated, ‘they've got a kit and then they've got the bottle…I don't know how the kit opens, how they put it in there…I have no idea about it…I just sell them’. Like P3(Y), who commented ‘I don’t know anything, I’m not smoking’ P1 suggested consumers who smoked were responsible for understanding how the devices worked.
Participants used numbers indicating nicotine content to compare ENDS with tobacco and suggest how customers might wean themselves off nicotine (three indicated the highest nicotine strength in a commonly stocked e-liquid range). P1(Y) explained ‘…number three got the same volume of nicotine we've got in the actual cigarette…If people are intend(ing) to drop down the volume of nicotine, they can use the number two or number one and… reduc[e] them day by day… then they come to shisha [a no-nicotine device] and… finish it’. While P1’s overview was correct, he later described offering contradictory advice, such as starting on zero-nicotine products: ‘ if the customer asks for it, like, ‘I want to quit’, so we offer them (electronic) shisha… this is what you can try, and buy that. We don't show the vapes, because vape is similar to the smoke… We show them directly shishas, like, which got no nicotine…. you can taste the flavour… and feel like you're smoking, but you're not getting any harmful chemicals in you.
Retailers’ views on advising consumers varied and some acknowledged they could not provide appropriate guidance: ‘The companies do give us a brochure that we can just pass on to them… there probably isn't enough training in store to be able to fully help somebody and make their mind up that this is the way that they should go’ (P12,Y). Others showed no interest in learning how to advise people wanting to quit smoking: ‘I will take their money, and that's it. But I most certainly ain't gonna stand there and say, ‘Well, look’, you know, ‘do you know how to use them, and if so… or if not, this is how’ I mean, if they're big enough to buy them, and old enough to buy them, they surely should be able to read the instructions’ (R4,N).
Perception of ENDS’ relative harm
Participants who sold ENDS lacked knowledge of devices usage and generally saw ENDS as similarly harmful to tobacco because both contained nicotine. P4(N) explained, ‘I mean, nicotine does a heck of a lot of damage to you…Over years. You know. I mean, one smoke or two, probably wouldn't do a thing… But if you get addicted to it and smoke like I did…Oh my gosh. It does a heck of a lot of damage… So they (ENDS) would too… I would assume’. P1(Y) noted ‘As the (ENDS supplier) says, they've got the same nicotine. So, same nicotine, same harm’. Confusion over nicotine appeared to arise from sales materials and led to misperceptions about the relative risks both products posed.
Retailers relied on customers’ comments about ENDS’ lower ongoing costs and convenience to ascertain why people used ENDS; only a minority saw ENDS as a potential reduced risk product. P2(Y) noted ‘It (ENDS) costs so much less. So it's eight dollars for the same amount that you pay 70 dollars for normal tobacco… they also tell me is… if they feel stressed, they can’t wake up at 2 o’clock and go outside the house to smoke, because normal smoke make lot of smoke around. Smell too. They can smoke this one in the bed too, and no, no smell’. Retailers commented on the increased control smokers reported, ‘You don't have to… finish your smoke (with ENDS) … you wanna smoke put in your pocket and then start again’ (P5,Y).
However, some felt smokers who used ENDS more intensively than they had smoked would negate benefits of switching to ENDS. P9(Y) commented: ‘I reckon it (ENDS) could potentially be worse than smoking, because they're just doing it continuously all the time…And it's still a lot, 18 milligrams is quite a bit of, you know, nicotine as well, so…I reckon to that extent it could be quite bad in the long run as well’. Some felt concerned about the greater ‘output’ produced by ENDS and saw larger ‘smoke’ volumes as exposing others to potentially harmful secondhand aerosol: ‘…there's a lot more ‘smoke’. I'm not sure if it is smoke or what that is that comes off them… but you see people in their car… and there's just huge puffs of smoke…I think it's a bit of an unknown as to how harmful it is on a secondhand perspective’ (P8,N). Others had heard about accidents, though these appeared to be secondhand accounts: ‘I heard about a couple cases, yeah. People get hot e-liquid…popped out or spilled from the pipe, and they got their lip or tongue get burned’ (P11,Y).
Capacity and willingness to advise customers on quitting smoking using ENDS
Most participants felt they could assist customers to quit smoking, though by offering information and encouragement, rather than specialist advice: ‘I think we should have a role as far as giving people the information on support networks… If there's someone with a gambling problem, they've got information downstairs as to where they can go to get help. I think that would be the extent of help we could offer. We certainly wouldn't have on-site counsellors or anything like that. But as long as we could give people information of where they can get help…Yeah. I think that would be enough’ (P8,N).
These comments delineated participants as information providers (as opposed to advisors) and reflected their view that smoking was a personal ‘choice’. Even those for whom tobacco sales presented a ‘dilemma’ rationalised smoking as ‘people’s choice’ and rejected pleas from customers wanting to quit smoking as outside their role of ‘to smile, take your money’. P11(Y) explained ‘Well, it's sort of dilemma, isn't it? 'Cause it's a part of the business. When you saying, you try to have a responsibility for the public, so it's sort of really a bit ah…. my priority is people's own choice. I respect people's choice, that's it’. P18(N) went even further: ‘I've had people coming in and saying, ‘If I want to buy cigarettes… don't sell them to me.’… From my point of view, I'm not getting involved. I'm not your mother, I'm not your caregiver. I'm here basically to smile, take your money’.
Stocking ENDS meant retailers could extend their product range, but they reiterated they would provide information rather than offer advice: ‘So what is my role? I would just tell them what was available. The choice is theirs…Yeah. I'd tell them that we have the cigarettes. I'd tell them what we had. If they ask for vaping, I'd tell them what we had, and then… the choice is theirs. I'm not there… to make their choice for them’ (P17,N). Aside from respecting personal choice, tobacco retailers felt reluctant to promote ENDS as a smoking cessation tool because they lacked specialist knowledge: ‘From a personal perspective… if you were a customer and decided to try and quit smoking using vaping… I'd probably go to a pharmacist. I don't know why, but, for me, a pharmacist would probably have more information’ (P10,N). Others queried whether ENDS helped smokers quit as they had seen customers relapse from vaping to smoking: ‘They're still two very different things, they're not the same, they're kind of similar, but… I've had a lot of people that have gone back to smoking’ (P9,Y).
Some felt concerned that ENDS merely replaced one addiction with another and focused on nicotine, which they say as the harmful component of tobacco rather than considering the relative risks of smoked tobacco and ENDS: ‘Yeah. I'm just not into the whole replacing one habit with another, and that's what I think you're doing if you stop smoking …If you're replacing it with an e-cigarette, you're still getting your nicotine. And then I'm like, ‘what are you going to do to get off the e-cigarettes?’ (P7,Y).
Perceptions of proposed legislation
Participants had little knowledge of proposed ENDS regulation though most felt existing tobacco retailers, including themselves, were appropriate ENDS retailers: ‘I suppose as long as it's not being sold at a place like um, like ‘Lollipops Playland’, you know, I probably wouldn't do that. But the typical dairies and liquor stores and most supermarkets as well, wherever you can buy cigarettes’ (P8,N). Others felt concerned they could be disadvantaged if other outlets could sell ENDS but they could not: ‘But have to sell (through) everyone, not only give it to like pharmacy, or petrol station. If you stop the dairy shops (convenience stores), it’s wrong’ (P6,N).
Most thought ENDS sales should be restricted to people over the age of 18 years: ‘…under 18 s don't need to be mucking around with stuff like that… I even frown on the kids come in and they wanna buy lighters and matches and things like that, I'm like, ‘what do you need that for?’ (P7,Y). However, one participant felt R18 restrictions could be counterproductive, if the legislation positioned ENDS as a harm reduction tool: ‘…if it's not very harmful then I mean, maybe even just 16 should be fine. Cause the lots of teenagers they start smoking before the legal age…And this, some way, they just get into this-…Less harmful than the other ones’ (P15,Y).
Other participants had thought policy decisions liberalising access to ENDS should await health impact studies. P9(Y) commented ‘…there's not much studies done into it yet, so we don't know… if they could be bad for you…it's hard to say, like I think this is one of those things that over time, like when they do, do the research and do all the testing behind it, then you'd be able to tell’. One participant had no interest in selling ENDS, which she saw as incompatible with her store’s positioning, and thought sales should be restricted to specialist stores: ‘probably just particular outlets I think, there's a couple of specialist tobacconist shops in (area) … I definitely wouldn't be interested in selling them… yeah, I mean we're supposed to be perceived as a grocery store’ (P18,N).
Several participants found it difficult to reconcile more liberal promotion of ENDS with measures to reduce smoked tobacco use. P8(N) explained ‘the only thing I probably would question would be the promotional side of it… what are the limits on the promotion of the product? Is it just point-of-sale? … I probably don't agree with that because… it's a product that still has nicotine in it and it is still promoting the act of smoking whether it be with or without nicotine’. P16(Y) raised more specific questions: ‘Why… advertise (and) have the (free) samples? That's encouraging people to smoke…I think that's the bad policy…If you sell, just sell. Why you have give a free sample? The people that not smoke, they'll come… to buy it…That means that you encourage… younger generation who are the people not smoke. They want to try it…You encourage them to go this bad habit’.
Some felt concerned promotions of addictive products could promote experimentation; P10(N) explained, ‘It's like pre-mixed (alcoholic) drinks… I call them ‘lolly waters’. But what's their target? I mean, their target's for people that don't like beer or wine, so let's give them an alternative so they'll drink…. it's just like the flavoured e-products… as a smoker, why would I wanna smoke apple blossom? It's not smoking, I'm sorry’. P15(Y) expanded on how ENDS’ novelty would appeal to youth: ‘Younger people… think it's fun. …Yeah they're just fun, interest, new product… people always wanna try new things when they're young’.
Experiences of selling ENDS
Of the 12 retailers who stocked ENDS, all reported a low demand for these products, which made up a tiny proportion of their overall turnover, despite sales reps’ claims: ‘They (company reps) were saying, ‘oh it's selling a lot’. It might sell a lot in town. But it doesn't sell here… I'm sitting with about $700 worth of stock at the moment…Yeah. I think I, from last 6 month, only sold one’ (P5,Y).
Unlike tobacco, where participants reported receiving incentives via rebates, had higher product turnover, repeat custom and perceived ancillary sales, they had little incentive to sell ENDS. Ironically, the main benefit of ENDS to consumers—reduced cost—was the main disadvantage to retailers. P13(Y) explained, ‘it's a small shop, so we want our customers to be repeat every time, to come again and buy the smokes and buy some other stuffs… if the customers buy the e-cigarettes, ones like the long-lasting, it's very hard… to get the customers back to the shop… Like I want the customer to come every day. At least four or five times a week so that, you know, you can buy some other things… And second thing is that like, we sign a contract with the (tobacco) companies and the companies are giving us some sort of rebates and so for e-cigarettes we're not getting any rebates’. Yet while most thought ENDS did not contribute to their business, they saw tobacco as essential: ‘… if my turnover for a week…is $10,000, uh, the tobacco cigarette, the sale, about $7000. So, if we're not sell this one (tobacco), the shop can close’ (P14,Y).
Discussion
Participants had limited knowledge of ENDS products and could not offer cessation advice to customers, which many saw as outside their role. Some provided inappropriate advice to customers, for example, advising them to switch immediately to a zero-nicotine product. Like many ENDS users,11 participants felt uncertain about ENDS’ attributes; several regarded nicotine as the harmful ingredient in tobacco and did not understand that tobacco combustion caused the harmful compounds found in smoke.17 Until they fully understand the relative risks of smoking and ENDS, there is a serious risk that non-specialist retailers may inadvertently undermine smokers’ transitions to ENDS use.
Tobacco contributed more to participants’ businesses than ENDS, through more frequent repeat custom and rebates from tobacco companies. If ENDS are to reduce harm, policymakers need to dismantle the strong supply and advocacy relationships tobacco companies have developed with retailers, and ensure the most harmful products are also the least accessible.18–20
Despite ENDS’ negligible contribution to their turnover, most participants viewed proposals to liberalise the sale of ENDS favourably. However, some felt concerned that point-of-sale promotions and displays (banned for smoked tobacco products in 1990 and 2012, respectively) would appeal to young people and could prompt ENDS experimentation.
Our findings have important implications for impending changes to NZ’s Smokefree Environments Act 1990,21 and for international tobacco control advocates and policymakers. First, the NZ Government believes ENDS could potentially support NZ’s Smokefree 2025 goal, which will only be achieved if smoking cessation rates increase rapidly.8 Yet, research examining transitions from smoking to ENDS use suggests some smokers find vaping uptake difficult, remain dual users or revert to smoking, despite wanting to quit.10 11 22 23 Even ‘pod mods’ such as JUUL, which are easier to use than tank mods, require fundamental behaviour changes. Allowing ENDS sales by staff with weak knowledge of these products and little commitment to go beyond their commercial remit seems unlikely to support smokers who want to quit, even those wishing to use less technically complex ENDS such as pods. Switchers need to learn how to use and maintain vaping products, find the ‘right’ combination of device and e-liquid nicotine concentration(s), and recreate ritualistic practices enacted with smoking.10
Second, behavioural counselling that manages smokers’ expectations, establishes fine-tuning as normative and assists development of new rituals could foster transition to exclusive ENDS use.11 Clear initial advice could reduce that the risk dual use becomes established and help smokers manage ‘sticky’ cigarettes smoked at critical time points (eg, on waking or after meals), or as part of other practices (eg, while drinking coffee or alcohol).10 24
Our findings imply that smokers who do not receive guidance at the point of sale may continue smoking and fail to switch completely to ENDS. The relative expertise of vape store staff compared with convenience store owners suggests limiting distribution to channels able to offer support could encourage perseverance with ENDS and reduce the risk of relapse to smoking. Retailers with a diverse product array, such as specialist vape stores, may also be better placed to advise on rapidly changing devices.11 Yet, while this approach would increase the support available to ENDS purchasers, it may reduce product availability, thus potentially reducing uptake and switching. Nonetheless, limiting ENDS distribution would reduce the risk that ENDS use becomes ‘normalised’. Other measures to reduce ENDS uptake among young non-smokers could restrict ENDS marketing, which mirrors past tobacco marketing (eg, use of celebrity endorsements and sponsorship to depict ENDS as fashionable lifestyle products)25–28), and in-store promotions that extend these themes.29–31
Restricting ENDS sales to pharmacies could ensure smokers receive cessation support while also reducing non-smokers’ exposure to these products. Although ENDS manufacturers, specialist vape retailers and ENDS users who do not wish to cease vaping may oppose such a measure, managing access to ENDS and supporting smokers to transition to ENDS, and then become vape-free, is crucial to realising the public health benefits the Government envisages.
Greatly limiting the supply of smoked tobacco and disallowing incentives offered to retailers alongside cautious increases in ENDS availability could rebalance the nicotine-product market in favour of less harmful options. Careful monitoring could identify positive effects and unintended outcomes, and enable availability to be fine-tuned. To create a nimble policy framework, policymakers should license ENDS retailers (and all tobacco retailers), require them to demonstrate knowledge of all devices they sell and make it mandatory to advise users they should ultimately stop smoking and then to quit ENDS use. This approach could manage commercial motivations to prolong ENDS use and promote ENDS cessation among those vapers who can quit. Within NZ, Smokefree Enforcement Officers, who oversee compliance with smoked tobacco product regulation, could also monitor compliance with regulations addressing ENDS’ sales.
Our study has some limitations: we cannot generalise from our small sample of retailers but the diversity of our sample is likely to have captured the range of views elicited by a larger qualitative study or a representative survey. The detailed data on participants’ beliefs are a key strength of our study, which is the first to explore how ENDS are sold. Future work could review the advice provided by specialist retailers including vape stores and pharmacies, and variations in advice quality by retailers’ own vaping experience. Such studies could inform future regulations and help develop criteria ENDS retailers must meet to obtain a licence.
In conclusion, convenience store owners who lack knowledge of the ENDS they sell may undermine rather than support smoking cessation. Policies regulating the availability of ENDS need to recognise the dynamic nature of the ENDS market and the acculturation process smokers undergo as they transition from smoking to exclusive ENDS use. Dramatically reducing the supply of smoked tobacco while restricting ENDS sales to specialist vape stores and health-promoting retailers, such as pharmacies, would recognise the relative risk of both products and support smokers to transition from smoking to exclusive vaping.
What this paper adds
Although there is an intuitive logic in allowing Electronic Nicotine Delivery Systems (ENDS) to be sold wherever tobacco is sold, many tobacco retailers have little understanding of the ENDS they stock and some provide incorrect advice on ENDS usage.
Dramatically reducing the availability of smoked tobacco and cautiously allowing increased distribution of ENDS would recognise the relative harms the two products present while ensuring smokers may access technical and behavioural advice to quit smoking.
Until retailers demonstrate thorough knowledge of the devices they sell and smoking cessation, sale of ENDS should be limited to licensed vape stores and outlets that already specialise in smoking cessation, such as pharmacies.
Allowing non-specialist tobacco retailers to sell ENDS products may reduce smokers’ access to advice and support that will facilitate a successful transition to exclusive vaping.
Acknowledgments
The authors would like to thank Dr Lucy Popova for helpful comments on an earlier draft.
References
Footnotes
Contributors LR and JH conceptualised the project and obtained funding; LR, JH and LM designed the interview guide and sampling procedure. LR and LT undertook the interviews. LR, JB, JH and LM analysed the data; JB, LR and JH led the overall MS development; LM and LT provided feedback on drafts. JH, LR and JB responded to the reviewers’ suggestions. JB is lead author and JH is senior author; other authors are listed in descending order of contribution. JB and JH are the MS guarantors; all authors have seen and approved the final manuscript version.
Funding University of Otago Research Grant, Department of Preventive and Social Medicine Strategic Grant.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval University of Otago Delegated Authority acting for the University Human Ethics Committee.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.