Evidence and uncertainty around e-cigarettes in tobacco control and smoking cessation services in Scotland

Abstract

BACKGROUND: The role of e-cigarettes and related vaping products in smoking cessation has been a contested topic across the tobacco control community. Existing literature has begun to examine how and why divergent ‘evidence-based’ positions around vaping are occurring across and within different regulatory and policy contexts. Within research on the United Kingdom (UK), the literature appears to primarily be driven by studies examining the English tobacco control and smoking cessation context. This thesis aims to investigate the distinctiveness of the Scottish tobacco control and smoking cessation landscape. In considering approaches toward e- cigarettes within the Scottish policy context, this thesis focuses on the perspectives and practices of Scottish tobacco control and specialist smoking cessation service (SCS) professionals. In particular, the thesis seeks to understand the characteristics of evidence mobilisation and experiences of ‘uncertainty' around e-cigarettes among Scottish tobacco control and SCS professionals. Beyond considering epistemic uncertainties, the thesis explores sources, experiences and management of metaphysical and moral uncertainties as related to personal, professional normative and political contextual influences on SCS practice.

METHODS: Using a qualitative multi-case study approach, this study examines how Scottish tobacco control and SCS professionals conceptualise, understand and engage with e-cigarettes in practice. Data was collected from 25 semi-structured qualitative interviews with Scottish and UK tobacco control and SCS professionals as well as Scottish and UK SCS policy, guidance and training documents, national consensus statements and policy actor position statements. Interview and document data were analysed thematically to understand the characteristics of evidence mobilisation and the sources, experiences and management of epistemic, metaphysical and moral uncertainties when engaging with e-cigarettes in practice.

RESULTS: The thesis includes three empirical chapters, each examining experiences and management of different forms of uncertainty. Chapter 4 reflects on issues of epistemic uncertainty. Interviewees recounted professional experiences of epistemic uncertainty via feelings of ‘under-confidence’ due to the perceived lack of practice-oriented training and the diversity and uniqueness of e-cigarettes. In contrast, epistemic uncertainty within the analysed documents primarily addressed concerns around the limited data on the safety and efficacy of e-cigarettes. To manage their epistemic uncertainty, interviewees relied on familiar approaches for which they felt more confident (e.g., medically licensed pharmacotherapies) or sought external sources of expertise (e.g., reputable vape retailers and guidance from UK and English public health authorities). Chapter 5 examines experiences of metaphysical uncertainty, illustrating how e-cigarettes have challenged the bounds of what is accepted as a legitimate smoking cessation tool and the extent to which harm reduction fits within the goals and delivery structures of Scottish SCSs. Management of this metaphysical uncertainty is presented as having been shaped by how professionals defined the goals of their SCSs – as within a spectrum of either complete abstinence from tobacco, nicotine and cessation aids or tobacco harm elimination and nicotine harm reduction. Chapter 6 examines experiences of moral uncertainty. This form of uncertainty is evident in questions of prioritisation and health protection of special-interest groups (i.e., young people, non-smokers and pregnant smokers) as well as practice-oriented concerns related to duty of care and conflicts of interest between public health efforts and e-cigarette manufacturers. Management at the practice level involved avoiding discussions of e-cigarettes in favour of familiar medical-licensed approaches and advocating for written, sub-population specific service guidance about e-cigarettes. Responses at the policy level, however, involved calls for precautionary measures to minimise the appeal of e-cigarettes to non-smokers and scepticism toward tobacco company-manufactured vaping products.

CONCLUSION: This thesis demonstrates how the complex Scotland-UK health policy environment and the professional norms and personal values of Scottish tobacco control and SCS professionals affect evidence mobilisation and decision-making around vaping in practice. In doing so, the thesis also illustrates the value of interrogating the forms and implications of ‘uncertainty’ surrounding the role of e-cigarettes in smoking cessation. While epistemic uncertainty is usually emphasised in policy debates, the thesis explains how metaphysical and moral uncertainties around the purposes and professional boundaries of smoking cessation significantly influence SCS professionals’ engagement with e-cigarettes in practice. Furthermore, these three types of uncertainty interact and inform one another; epistemic uncertainty around the safety and efficacy of e-cigarettes, for example, raises moral concerns for practitioners around the acceptable thresholds of risk and challenges metaphysical positions about using non-medically licensed products. While SCS professionals generally perceived evidence as key for reducing their feelings of under-confidence and anxiety around e-cigarettes, evidence mobilisation appeared to also have its limitations as an uncertainty management strategy. Whereas epistemic uncertainty was reduced by some professionals through gaining personal knowledge and confidence in discussing e-cigarettes, metaphysical and moral uncertainties could not be managed in the same way. Instead, these two types of uncertainty were handled by deferring to familiar practices, engaging in professional ‘boundary-work’ and advocating for structural changes and clarifications of SCS goals and responsibilities.