"It's Cool, Modifying and All, but I Don't Want Anything Blowing Up on Me:" A Focus Group Study of Motivations to Modify Electronic Nicotine Delivery Systems (ENDS).

INTRODUCTION: Modifications to electronic nicoti ne delivery systems (ENDS) can pose health risks to users. This study explored users' motivations for modifying ENDS devices and how perceived risks of modifications influenced modification behaviors as product availability and device characteristics changed over time. METHOD: We conducted nine focus groups (February-June 2020) with 32 current ENDS users (18+, used ENDS in the past 30 days, and had been using ENDS for more than 2 months). RESULTS: Participants primarily modified ENDS devices to improve their experiences, such as experimenting with flavor, controlling nicotine levels, or using cannabis products with ENDS. Another reason for modifying was routine maintenance to ensure a satisfactory experience, including maintaining coils and keeping batteries charged. The broader availability of ENDS products shifted modification behaviors over time, with newer devices making some modifications (e.g., coil replacement) easier and making more intricate modifications (e.g., building coil from scratch) less common. Participants were aware of modification dangers and cited perceived risk as the reason for avoiding certain modifications, such as battery alterations. CONCLUSIONS: Modifications of ENDS are ongoing and evolving among users and should be considered by the Food and Drug Administration (FDA) and other regulatory decision-makers as product authorization reviews are conducted and product standards are developed.