Acceptability of a Telehealth Smoking Harm Reduction Intervention Using E-cigarettes Among Cigarette Smokers With Opioid Use Disorder: A Qualitative Analysis

Abstract

Background:

Electronic cigarettes (EC) may serve as a potential smoking harm reduction tool by addressing both nicotine and behavioral dependence. This qualitative study reports the feasibility and acceptability of using EC and telehealth counseling among individuals in treatment programs for opioid use disorders (OUD) who smoke combustible cigarette, and was conducted as part of a randomized controlled trial. We report findings among participants in the EC arm.

Methods:

Qualitative interviews were conducted from March to May 2021. The interviews were audio recorded, transcribed, and de-identified. An inductive approach guided by the Theoretical Framework of Acceptability was used. We developed and refined a codebook through a collaborative iterative process and team discussions. Five analysts coded the transcripts using Quirkos, with independent double coding for each transcript to achieve consensus and ensure inter-coder reliability. In-depth thematic analysis was conducted via synthesizing relevant codes that were described and exemplified using representative quotes. Saturation was achieved when no additional codes emerged.

Results:

Eleven participants randomized to EC were interviewed: average age = 55 years (range = 39-69), 88% were male, 41% non-Hispanic black, and 35% non-Hispanic white. Four main themes identified included inciting sense of accountability toward cigarette smoking reduction; acknowledging the value of telehealth counseling; noting positive attributes such as addressing craving, as well as challenges in utilizing EC such as the need to remember charging the EC; and finally, participants’ expression of the satisfaction with their perceived improvements in their health and other behavioral aspects.

Conclusion:

The intervention combining telehealth counseling with EC was perceived as acceptable and helpful for reducing cigarette smoking, as well as resulting in other positive health benefits. ECs were easy to use and seemed to address craving; albeit with some challenges that can be addressed in future trials. EC combined with telehealth counseling carries great promise in smoking reduction among individuals with OUD.

Introduction

The prevalence of combustible cigarette (CC) smoking among individuals with opioid use disorders (OUD) is much higher compared to that of the general population. ¹ Those with OUD who are interested in quitting face significant challenges given their usually high nicotine dependence and the behavioral triggers reinforcing their smoking habits. ² Such higher level of nicotine dependence likely makes quitting significantly more difficult due to the associated intolerance to withdrawal symptoms. ³ Further, they often fail to initiate tobacco treatment, ⁴ and experience multiple care utilization barriers ⁵ hindering their use of available tobacco treatment programs. ⁴ It is paramount to support individuals with OUD tobacco treatment since it can also improve substance use treatment outcomes and quality of life, given the links between smoking, substance use relapse and premature mortality. ⁶

Nicotine replacement therapy (NRT) is one of the most cost-effective treatments among CC smokers in the general population. ⁷ However, no study to date has shown evidence of long-term success (more than 12 months) among people with substance use disorders. ⁷ CC smokers with OUD particularly suffer from high intolerance to nicotine withdrawal discomfort. ⁸ Hence, there is a need for novel tobacco harm reduction interventions among CC smokers with OUD. ⁹ E-cigarettes (EC) can likely mitigate the morbidity and mortality risk associated with smoking as a form of smoking harm reduction among CC smokers with OUD potentially rendering EC a more practical and pragmatic approach. ¹⁰ Furthermore, it has been hypothesized that ECs could be a more effective way to help individuals reduce the harm of smoking by decreasing the number of CCs smoked per day (CPD) or to quit smoking completely by addressing both nicotine and behavioral dependence. ¹¹

We conducted a pilot randomized controlled trial to evaluate the feasibility and acceptability of using EC versus NRT among smokers in outpatient OUD treatment. The study delivered brief harm reduction motivational interviewing counseling in a telehealth format, either over phone or video counseling depending on preference and technological feasibility at the time of the session. ¹² Participants received up to 5 sessions and counselors were instructed to keep each session between 15 and 20 minutes and no longer than 30 minutes. The goal was for participants being counseled to reduce CC smoking using EC and addressed switching as the main goal of the intervention via motivational interviewing and proper education on EC use. As part of the study, semi-structured qualitative interviews were conducted to evaluate the acceptability of the intervention among study participants post study completion. In this paper, we discuss the findings from the interviews of participants randomized to the EC arm.

Methods

Study Design and Population

This was a qualitative study embedded within a feasibility randomized-controlled trial, the results of which will be published in the future. Using a purposive sampling approach to include participants who managed to reduce their smoking by at least 50% as well as those who have not been able to reach this threshold, qualitative interviews were conducted with study participants between March and May 2021 to assess acceptability and feasibility of the intervention. Participants were eligible if they smoked at least 5 CCs per day, were 21 years or older, were enrolled in an OUD treatment program for at least 12 weeks and were interested in reducing CC smoking. The participants invited for these interviews were recruited from randomized participants to the EC arm. Participants in this arm were provided with Vuse EC and tobacco flavored cartridges, manufactured by RJ Reynolds as part of the study. This ensured consistency in product exposure and minimized variability in EC-related experiences. The research staff obtained digital e-consent for conducting and audio recording the interviews with participants. The study protocol and the interview guide were approved by the New York University Grossman School of Medicine institutional review board. The interview guide was constructed to include the relevant acceptability domains and comprehensive set of probes pertaining to the components of the intervention, namely the harm reduction counseling and EC. The interview guide is presented in Supplement 1. Participants received up to 5 counseling sessions and were also asked to complete a baseline survey, 3 research visits including survey measures in-between those counseling sessions, as well as an end of intervention survey. Participants were compensated for their time during the research visits. Those who participated in the qualitative interview received an additional $25 for their time.

Counseling Sessions Content

At baseline, after randomization, participants in both the EC and NRT arms received their first telehealth session (20-25 minutes) from a counselor trained in motivational interviewing, harm reduction, and smoking cessation, delivered via WebEx (Web conferencing platform, Cisco, San Jose, CA, USA) or phone, based on participant preference). Up to 4 additional sessions were delivered (with target scheduling on weeks 2, 3, 4, and 6), 15 to 20 minutes each. Counseling sessions were mainly conducted by the same counselor for each participant. The purpose of the counseling was to discuss the impact of continued smoking on their health and provide information on the relative harm of continued smoking versus reduction of CPD in both study arms, and deliver motivational enhancement counseling targeting CC smoking reduction using EC among the participants of the EC arm. Participants in the EC arm were encouraged to switch to electronic cigarettes as part of the harm reduction counseling, but they were not mandated to switch or reduce their cigarette consumption. This included instructions on EC proper use toward a harm reduction goal, such as using EC to replace CC as much as possible and substituting the first CC in the morning. The counseling protocol also includes problem-solving and behavioral skills endorsed by the national smoking cessation guidelines ¹³ and was adapted using the Information-Motivation-Behavioral Skills (IMB) model. ¹⁴ In both study arms, the counseling allowed participants the flexibility to set their own smoking reduction goals based on their readiness and preferences.

Data Collection

Eleven interviews were conducted among participants from the EC arm by the principal investigator (PI; OES) who had extensive qualitative research experience during his PhD studies and later his research, as well as two other trained interviewers from the research team. The interviews were conducted and audio recorded post study intervention completion via WebEx. Interview duration ranged from 30 to 45 minutes. The audio recorded interviews were transcribed verbatim through a transcription company. The transcripts were further proofed by research team members to remove names and identifiers ahead of formal analyses.

Data Analysis

An inductive approach of data analysis was adopted in line with our research question for evaluating the feasibility of EC as a harm reduction tool among people who smoke with OUD, as well as the benefits of telehealth counseling within this context. A codebook was developed via a collaborative process and informed by the Theoretical Framework of Acceptability (TFA) ¹⁵ with focus on the following constructs in particular: affective attitude, burden, intervention coherence, perceived effectiveness, and self-efficacy. Four research team members (AF, MB, BK, NH) and the PI (OES) independently read three interview transcripts and generated potential codes based on the key domains of interest that had been identified a priori based on the TFA constructs. Research team members met to create a preliminary codebook by organizing their findings into codes, sub codes, and definitions. Participant responses and quotes were classified to align with the initial codebook with new codes generated when warranted during discussions. The preliminary codebook was then applied to a new set of 3 transcripts. The research team met to discuss discrepancies, consistency in coding application and modified the codebook as necessary. In some cases, codes and sub-codes overlapped across themes, as certain aspects of participants’ experiences were relevant to multiple domains. When coding team members encountered responses that fit within more than one theme, double-coding was used to ensure comprehensive categorization. During analysis, these responses were reviewed to determine their most appropriate thematic placement while maintaining consistency in interpretation. This approach ensured that themes remained distinct while still capturing the complexity of participants’ experiences. Inter-coder reliability was above 85% overall. The transcripts were then divided among 4 analysts (MB, BK, MD, NH) who independently coded based on the codebook generated using Quirkos, which is an online cloud-based qualitative analyses platform that facilitates interactive coding and consensus evaluation. ¹⁶ The PI (OES) and an experienced qualitative research analyst (AF) supervised the coding process; assessed coding quality; led weekly team meetings to discuss coding progress and resolve queries from the team. All interviews were double coded from 2 of the 5 primary coders and saturation was set to be achieved when no new codes emerged. Finally, in-depth thematic analysis for this paper was undertaken by the research team by synthesizing all the relevant codes. These themes are described and exemplified using representative quotes.

Results

Participants interviewed had an average age of 55 years (Range: 39-69). Most participants were male (88%), mainly identified as Non-Hispanic Black (41%) or Non-Hispanic White (35%). Four main themes were identified from the analysis: (1) Participation in the program provided a sense of accountability toward reduction in CC smoking; (2) The beneficial effect of telehealth counseling on participants; (3) EC have multiple positive attributes as well as some challenges in using them; (4) Participants expressed overall satisfaction with the perceived improvements in their health and other lifestyle aspects. Taken all together, these findings, described in the sections below, highlight the acceptability of EC and telehealth counseling among people with OUD who smoke.

Theme 1: Participation in the Study Inspired Accountability Toward Cigarette Smoking Reduction Throughout the Intervention

Participants often expressed favorable views and sentiments about the impact of participation in the intervention as a whole, as well as its different components in promoting accountability toward reducing CC smoking as the overarching goal of the program. The regular interactions with the study team members and counselors were seen as valuable reminders to stay committed and achieve their goal. For example, one participant noted “I felt like I was part of something [the study]. It wasn’t like there were days going by where I didn’t hear from anybody or anything . . . . It was always a very cooperative thing . . . and it helped me a lot just that alone.” Moreover, the components of the intervention further supported establishing clear targets for their participation. One EC participant commented on selection of a quit date that “. . . I like how the program starts off kind of right off the bat with you with a date that, ‘Hey. Why don’t you go ahead and mark a quit date? And while you’re at it, why don’t you see if you can keep that quit date and we’ll check in with you to see how you’re doing with it.’” Another component was tracking smoking habits and number of CCs, one participant emphasized “. . . I definitely felt it was extremely good, because I was allowed to be able to really sit back and analyze like ‘Wow. You are smoking this amount a month of cigarettes.’” Also, the same interviewee noted that frequent counseling enhances accountability: “. . . and when you have someone calling you on a weekly basis and keeping you accountable, it definitely does keep that in the back of your mind when you’re gonna go smoke a cigarette.” Participants acknowledged an improved level of behavioral control with helping achieve complete smoking abstinence for some, while in others, contributed to a reduction in the number of CCs smoked daily. One participant noted “It [the intervention] definitely has kept me accountable. I have slowed down on smoking, and I’m much more mindful of the cigarette intake that I do now . . . I’m not smoking as much cigarettes.” Although participants mostly found the counseling to be conducive to their progress, they reported that some of the assessment questions for the surveys delivered between counseling sessions were challenging to address as one participant said “I thought some of the questions, the way they were posed, were a little awkward sometimes . . .,” or was not supporting their experience with the intervention, “. . . the questions, the anxiety, ‘Do you have anxiety?’ That’s not really helpful,” or at times redundant, “You ask the same questions over and over again. It becomes a little mundane. Like what’s the point?”

Theme 2: Telehealth Counseling Supported Positive Behavioral Change Efforts and Acted as Reminders for Achieving the Smoking Harm Reduction Goal During the Intervention

The telehealth counseling component of the intervention was particularly well received by the participants. An overarching sentiment was how participants became more aware of how smoking and the habits associated with it impacted their lifestyle. An interviewee noted that interaction with counselors enhanced their self-awareness of smoking habits and how it is interacting with other emotions or behaviors that takes place frequently in their life by saying: “they [the counselors] helped me open my eyes to certain things, like when I get upset, I do want to smoke. When I get up in the morning, I do want to smoke, and I wasn’t paying any of that any attention before, so it kind of brought it to my attention, and then by them bringing that to my attention about when I get upset and all of that, or when I’m nervous or have anxiety, I want to smoke, and so when I get that way, it would be in the back of my mind that, ‘Oh wow. I want a cigarette now because I’m getting coffee . . . It kind of just opened my eyes to that, made me realize what triggers me to smoke: certain moods, certain situations, certain surroundings. It brought all that to the light. It made me understand that.’” Participants enjoyed the conversations with the counselors and found them to be quite knowledgeable and professional as one participant with prior experience working as a behavioral counselor noted; “I thought the counselors were excellent. They were very helpful. They used Motivational Interviewing techniques. (There was no) criticism, judgment, so it was excellent.” Participants expressed satisfaction with the content of the counseling sessions. However, some indicated a preference for more frequent sessions, and in certain cases, longer sessions as well. As noted by one participant. “The length of time, it was like 30 minutes. I feel like it could’ve been longer.” Participants highlighted the benefits of the counseling sessions, such as the accountability it provided, and the ‘goal setting’ techniques that the counselors helped create. As one participant stated, “. . . speaking to someone about what was going on and developing a plan with the person that I was speaking to . . . they were helpful in developing a plan . . . and having somebody to answer to gives you more motivation.” The constant communication from the study team throughout the intervention period proved to be beneficial for the participants. One participant stated: “The weekly calls and talking about it . . . I felt everything about the program was helpful because it definitely made me really track how much I’m smoking and take accountability for myself, and it really made me realize that, you know.” Participants preferred having video sessions to phone calls. The video sessions made the counseling feel more personal. A participant stated: “I would choose the video . . . I’m comfortable like being in the room with someone . . . It’s a lot better than the phone . . .” There were no negative aspects mentioned regarding delivery in telehealth counseling sessions.

Theme 3: There are Noted Benefits and Challenges When Using Electronic Cigarettes

Participants conveyed an overall positive experience with the intervention agent, acknowledging its significant assistance in their endeavor to quit smoking: ECs appeared to be a viable and acceptable replacement to combustible CCs, albeit with some challenges.

Positive Aspects of E-cigarettes

EC was well-received and considered a viable alternative to traditional CCs by several participants. One participant noted that “I like it because I quit smoking cigarettes, I’m comfortable with the E-cigarette, but I have no desire for a cigarette, like a real cigarette.” Some participants acknowledged the EC’s effectiveness in addressing the specific craving for smoking. A participant stated that “. . . The E-cigarette definitely helps with the craving for smoking traditional cigarettes.” In addition to helping with cravings, ECs aided some participants in reducing the frequency of smoking. For some, the experience was such that they could forget about CCs altogether, as mentioned by another participant. “. . . if I do crave, I take one, two puffs and I don’t need to smoke anymore. As far as a cigarette, I don’t even think about a cigarette.” Furthermore, the similarity in behavior ritual between smoking CC and smoking EC was another reason for tolerating ECs. A participant commented on the ease of use of the EC, stating; “Well . . . E-cigarettes are so easy. You just hang it in your mouth . . . instead of me reaching for a cigarette, I’ve been reaching for the E-cigarette.” EC offered an added benefit of having appealing flavors and emitting a non-pungent odor indoors and on clothing which participants appreciated, as a participant noted “. . . I enjoy it. I can use it everywhere, and I like the different flavors it comes in, and I like [it doesn’t make] my house stink, my clothes stink . . . The ease of access to ECs played a vital role in its acceptability.” Participants particularly appreciated the convenience of having it delivered directly to their homes during the intervention. One participant noted. “I got this thing delivered to my door. It was no effort. I’ve been telling myself for months, probably even years, that I’ve got to quit, so but I never really made the first couple of steps to do it . . . I just had to figure out how to use it, and then it was very simple after that.”

Challenges Imposed by E-cigarettes

Not all comments regarding ECs were positive; some participants initially experienced discomfort when using the EC, leading to coughing, as they were not accustomed to its potency. However, they became comfortable after learning to use it properly. A participant stated “. . . I do the E-cigarette probably six or seven times a day, but at first I didn’t like it because it was very strong . . . You know I was taking very big drags and I was coughing all the time. Once I learned how to just take it easy and just learned how to do it right, it’s getting better and better all the time.” A handful of participants highlighted challenges related to owning a single EC, such as the inconvenience in the event of it going missing and difficulties with EC battery charging. One participant pointed out these issues. “. . . I have a busy lifestyle and I change bags a lot, so and then one of them went dead on me at one time . . . for some reason the battery stopped working, the recharger stopped working . . .” Another participant commented on the challenges they encountered in continuing with the specific brand of EC after the study conclusion. “I felt like the program was just a little bit too short . . . because they then stopped providing the E-cigarette that I became accustomed to and that was not available where I can purchase and continue to refill . . .” The same participant was able to find another EC brand that they enjoyed and found EC to be helpful in smoking reduction. “. . . now I have to find a new vape that worked for me, that I knew that was safe and that wasn’t artificial . . . but I have noticed that it has worked for me because I have cut down tremendously on cigarettes.” The constant access to ECs was raised as a drawback to smoking cessation. One participant emphasized that having continuous access to the EC could lead to increased smoking, stating, “. . . . With the E-cigarette, you could smoke this anywhere. I’m in my office right now . . . I have it at my disposal. I could basically vape anywhere . . . ‘cause you have it right here in your hand or your pocket at all times ready to go . . . You have to, of course, control yourself.’”

Theme 4: Participants Were Satisfied with the Perceived Impact of the Intervention on Their Health and Other Lifestyle Aspects

Several participants expressed feeling overall improvement in their health. One interviewee noted improved stamina; “I can run now . . . I’m not about to die, if I take a quick little jog (to get to a) bus stop or train station a little faster.” Many participants noted significant health differences, including reduced coughing and improved breathing compared to before participating in the study. A participant highlighted that the improvement in breathing motivated them to engage in more vigorous activities, stating, “I can breathe easier, so I am more motivated to exercise.” Furthermore, participants communicated an overall positive impact of the intervention on their financial well-being. They are spending less on purchasing CCs, thus enabling them to save more money. “. . . it’s changed quite a bit. I got more money in my pocket. It’s an expensive, deadly habit,” a participant noted. Another participant mentioned they had been able to reduce the number of CPD by replacing them with smoking ECs. “. . . I started at 16 to 20 [cigarettes] a day . . . I smoke maybe ten cigarettes a day, and I do the E-cigarette probably six or seven times a day . . . but I’m close to having it replace the regular cigarettes.” Some participants endorsed that the combination of a nicotine alternative alongside counseling worked better than past cessation attempts: “. . . from past experience, I thought I could stop. No. It’s hard, but by entering the program and then with the E-cigarettes, it helped tremendously.” Several participants displayed a high level of understanding regarding the impact of EC on their ability to eventually stop smoking. One participant highlighted this by saying “. . . if I can trust what I read, science, or what’s in the papers, E-cigarettes are less harmful than regular cigarettes. If that’s true, and I believe it is, then to me it’s a great way to get off cigarettes, because trying to just quit cold turkey is very, very hard . . . I’ve done it when I had to for a few days, but I always go right back. This gives you something to just kind of transition into not smoking. It takes away your cravings, but it doesn’t give you that full cigarette satisfying feeling, which is good, because you want to start tapering down and eventually quitting . . . I’m getting used to less and less nicotine in my body.” Finally, a participant summarized the impact of the EC by comparing it to the other methods they had previously attempted to reduce smoking without success. “. . . I tried the gum before. I’ve tried something called Wellbutrin years ago . . . It didn’t seem to work, but the E-cigarettes . . . It has.”

Though the consensus among participants was that the ECs were less harmful than CCs, they still expressed ambivalence about the alternative and its potentially negative health consequences: “Well you know I am not sure if they’re completely harmless. I’m sure there are negative effects, negative health consequences.” Another participant with similar reservations hoped to also quit smoking ECs in the future. “I mean I wish I could stop the E-cigarettes now. I feel like I’m addicted to the E-cigarettes, but I enjoy them, and I know that’s probably not good.” In identifying the source of their skepticism, participants cited their peers, “My friends tell me it’s dangerous so I don’t particularly like the E-cigarette,” and external media resources. “. . . there was a big thing that came out not too long ago about the E-cigarette and the vape pen and how 50 years down the line, what are your lungs gonna look like? Are they gonna promote lung deterioration and all that stuff? That’s the only thing I’m skeptical and worried about.”

Discussion

This study found that a novel intervention combining telehealth behavioral counseling with EC for reducing CC consumption was perceived as acceptable and satisfactory among individuals currently in drug use treatment who smoke CC. Specifically, participants emphasized how engagement in the intervention provided an improved level of accountability, highlighted the beneficial effects of participating in telehealth counseling, and called attention to the perceived positive impact of the intervention on their health and lifestyle. While generally perceived as an acceptable component of the intervention, participants also pointed to the challenges associated with switching to ECs; emphasizing the need for further patient support when introducing EC as an aid for smoking reduction. This study adds to the growing body of literature supporting the use of ECs for harm reduction in patients with OUD who smoke.^17,18 Our results suggest the potential for the use of ECs combined with telehealth counseling as a tool for smoking reduction among individuals with OUD.

As observed in previous research,^{19 -21} study participants highlighted EC characteristics – such as their mimicking the behavior of CC use, convenience, appealing odor and flavor, and nicotine delivery – that make ECs an attractive replacement for CCs. However, participants also mentioned challenges to maintaining their EC use. Many of the mentioned barriers to EC use have been observed in other populations, such as a dislike for the harshness of the throat-hit, concerns over EC reinforcing continued nicotine addiction due to its convenience, as well as access to preferred devices and cost.^22,23 Interestingly, in addition to other often documented barriers to EC use, participants specifically discussed the challenges associated with relying on a singular device, rather than a multi-pack of CCs, that could be misplaced or lose charge. The intervention included information about proper use of ECs, which was noted as very helpful by participants. The mechanics of EC use are different than CC and teaching an individual how to properly operate the device may help alleviate some of the discomfort and confusion associated with new EC use. Additional educational materials for patients switching to EC for smoking reduction may serve as a means of addressing a number of these cited challenges. Similarly, cognitive training can improve memory and provide individuals with strategies for memory aids, including among those with OUD,^24,25 therefore including cognitive training for remembering EC devices in program onboarding may help support a population more likely to be impacted by cognitive impairment. ²⁶ Further research is needed to develop an effective and comprehensive educational program to best support the transition from CC to EC among those in OUD treatment programs. While our findings indicate that integrating counseling with EC was perceived as helpful by participants as a combined program, evaluating the unique impact of integrating counseling versus delivering EC only warrants further research.

Study participants emphasized the importance of feeling “part of something” and described their increased engagement with the program as a result of regular participatory components of the study intervention that kept them accountable such as speaking with a counselor, tracking CC use, and setting quit date goals. Nevertheless, one participant noted that being part of the study reinforced their commitment to reducing cigarette use. This suggests that while the intervention played a crucial role in supporting smoking reduction, study-related factors such as structured check-ins and engagement with research staff may have also contributed to participants’ sense of accountability. Future research should further disentangle the effects of study participation from the intervention itself to better understand the mechanisms driving behavioral change.

Although, participants recommended continued communication with counselors and a flexible communication schedule to improve acceptability and enhance engagement, the impact of counseling was perceived as helpful. Indeed, consistent with previous research,^12,27 in a telehealth format, counseling was perceived as both beneficial and feasible among patients with OUD. Telehealth counseling, whether by phone or video, overcomes logistical barriers to in-person counseling (eg, time, cost of transportation),^28,29 and other treatment utilization barriers specific to OUD population (eg, negative or stigmatizing experiences with providers).^5,30 The multiple-component aspect of the studied smoking reduction intervention was perceived as contributing to participant enthusiasm and encouraging their smoking reduction efforts. Creating a sense of program involvement may play an important role in supporting smoking reduction efforts in this population regardless of the pharmaceutical support (ie, NRT, EC, medications) provided. Given the low utilization of tobacco treatment programs within this population,^4,31,32 future research should explore multi-component interventions designed to provide a sense of program engagement beyond that provided by standard counseling.

In addition to the sense of being engaged with the program, participants also noted feeling satisfied by the perceived impact of the use of ECs on their health and lifestyle, thus encouraging them to continue in the intervention. This noted pattern is consistent with IMB model in the context of tobacco harm reduction.^14,33,34 For example, information about relative EC/CC harm and perceived improvement in health outcomes can strengthen motivation and contribute to EC switching behaviors, and improved health outcomes which, in turn, enhance intervention adherence over time.^35-38 Prior tobacco treatment intervention studies have similarly targeted IMB factors among patients with OUD who smoke.^14,33 The emergence of this theme emphasizes the potential impact of considering IMB model factors in the development of future tobacco treatment interventions for this population.

This study had few limitations. First, the purposeful sampling of interview participants, and this analysis specifically, to select participants from the EC arm may have introduced selection bias, as those in the NRT arm of the trial may have differing views on some program components, as compared to those in the EC arm. Most of the participants in our pilot were males, which limits our understanding of potential sex differences in the acceptability of using EC among women in substance use treatment who smoke. Additionally, while our findings provide initial insights into this population, future research should examine potential differences in age groups, smoking history, and severity of OUD to better tailor interventions for subgroups that may respond differently. Finally, understanding the perceptions of younger people in OUD treatment programs who smoke is warranted given that most of our participants were older. Younger participants may find EC more appealing or may not experience the same challenges reported in our sample. Additionally, subgroup variations, such as differences in smoking behaviors among individuals with varying levels of opioid dependence, relapse risk, or prior quit attempts, remain unexplored. Future research should investigate these subgroup differences to refine intervention strategies and maximize effectiveness. While counseling sessions were monitored for fidelity, there remains the possibility for counselor-specific effects. Future studies with sample sizes allowing for more power to conduct statistical analyses should consider an examination of these potential effects. Finally, OUD may influence smoking behavior through heightened sensitivity to withdrawal symptoms and shared triggers for both nicotine and opioid use, such as stress or environmental cues. ECs may address these challenges by mimicking the sensory aspects of smoking (eg, mouth to hand movement), helping manage both physical and psychological dependencies. ³⁹ These were not explored in this study and future research should investigate these interactions to better tailor interventions for this population.

Conclusion

An intervention combining telehealth counseling with EC was perceived as acceptable and helpful for reducing CC consumption among those with OUD. The results of this study suggest the potential for the use of EC combined with telehealth counseling as a tool for CC smoking reduction among individuals in OUD treatment programs. Future research on tobacco treatment interventions among OUD populations may be considered a multi-component program that promotes engagement and incorporates IMB model factors including additional EC use training.

Supplemental Material

sj-docx-1-sat-10.1177_29768357251337050 – Supplemental material for Acceptability of a Telehealth Smoking Harm Reduction Intervention Using E-cigarettes Among Cigarette Smokers With Opioid Use Disorder: A Qualitative Analysis

Supplemental material, sj-docx-1-sat-10.1177_29768357251337050 for Acceptability of a Telehealth Smoking Harm Reduction Intervention Using E-cigarettes Among Cigarette Smokers With Opioid Use Disorder: A Qualitative Analysis by Omar El-Shahawy, Adetayo Fawole, Brian Kang, Mohsen Abbasi-Kangevari, Mariana Braga, Nada Hamade, Mohamed Doucoure, Jennifer Cantrell, Scott Sherman, Svetlana Shpiegel, Daniel Schatz and Elizabeth R. Stevens in Substance Use: Research and Treatment