Switching from Cigarettes to E-Cigarettes and Oral Nicotine Pouches in Adults with Low-Income Who Smoke: Qualitative Findings from a Pilot Randomized Controlled Trial

Introduction: Adults with low-income (LI) are more likely to smoke. Alternative Nicotine Delivery Systems (ANDS) like electronic cigarettes (EC) and oral nicotine pouches (ONP) are less harmful options that may help reduce the use, and ultimately risk, of combustible cigarettes (CC). This study examined facilitators and barriers to switching from CC to either EC or ONP among LI adults who smoked daily, enrolled in a randomized controlled trial. Methods: Thematic analysis of semi-structured one-on-one interviews with experimental group participants (n = 26) was implemented to identify themes related to the facilitators and barriers to switching from CC to EC or ONP. Results: Facilitators of switching to EC and ONP were the convenience of using these products in public and private spaces, their effectiveness at satisfying cravings for nicotine, and the perceived belief that ANDS are less harmful than CC. Barriers to switching to ANDS included delayed nicotine delivery, preferring the sensory experience of smoking to ANDS, and limited knowledge and misconceptions about ONP compared to EC. Conclusion: Participants indicated that both EC and ONP helped them cut down on CC use due to their convenience and ability to satisfy nicotine cravings. However, while participants believed that ANDS are less harmful than CC, more information is needed, specifically on the safety of ONP. Implications: This study presents compelling evidence that ANDS products are acceptable among LI populations who smoke, suggesting they could be used for reducing health disparities and mortality. However, public health education and messaging regarding ONP may be needed to facilitate switching.