European adult smokers' perceptions of the harmfulness of e-cigarettes relative to combustible cigarettes: cohort findings from the 2016 and 2018 EUREST-PLUS ITC Europe Surveys

Smokers' perception of the comparative health risks of cigarettes, e-cigarettes and heated tobacco products: a survey among the German population

BACKGROUND

Tobacco cigarettes, e-cigarettes and heated tobacco products can pose different health risks (harm continuum). As current tobacco smokers could benefit from switching to less harmful products, we aimed to assess current smokers' perceived comparative health risks of these three products and to explore associations between risk perceptions and specific user characteristics.

METHODS

We analysed data from 11 waves (2019-2021; N = 5657 current tobacco smokers) of a representative, cross-sectional household survey conducted in Germany. Associations were assessed with multivariable logistic regression models.

RESULTS

55.2% of smokers (95%CI = 53.8-56.5%) ranked cigarettes as the most harmful product. 36.1% of smokers (95%CI = 34.8-37.3%) perceived e-cigarettes and 33.8% (95%CI = 32.5-35.0%) heated tobacco products as more harmful than cigarettes. Misperceptions that e-cigarettes or heated tobacco products are more harmful to health than cigarettes increased over the 3-year study period and were more common among those with lower educational attainment.

CONCLUSIONS

Only half of current tobacco smokers in Germany perceive the comparative health risks of cigarettes adequately and such misperceptions have increased recently. As current smokers could benefit most from switching to less harmful products, educational campaigns are needed to inform this group about the health risks of tobacco smoking and the comparative health risks of the various nicotine and tobacco products along the harm continuum.

Perception of Health Risks of Electronic Cigarette Use Among College Students: Examining the Roles of Sex, Field of Study, Vaping Device Type, and Their Associations

Electronic cigarettes are marketed as a safer alternative to regular (combustible) cigarettes, based on the claim that there is no tobacco burning and fewer toxic chemicals in their vapor. However, recent evidence challenges the notion that e-cigarette aerosols are benign. Heating of compounds in e-liquids to high temperatures can lead to the release of toxic compounds in e-cigarette aerosols. However, users and the public may not be aware of these unique harms, impacting their perception of harm from using e-cigarettes. This research explored the perceptions of harm of e-cigarettes compared to regular cigarettes among 418 college students, aged 18-34, by employing a Qualtrics based smartphone survey. The findings revealed a vaping prevalence of 16.7% among our study population, indicating e-cigarette use among college aged young adults is at concerning levels. Perceptions of harm varied significantly by vaping status, sex, and field of study. Non-e-cigarette users and female students were less likely to perceive e-cigarettes as less harmful than regular cigarettes. Among e-cigarette users (vapers), male vapers and users of pod-type devices, such as JUUL and disposables, were more inclined to view e-cigarettes as less harmful. Among vapers, students in non-health-related fields were significantly more likely to perceive e-cigarettes as less harmful than regular cigarettes, underscoring the impact of educational background on health risk awareness. In conclusion, this study provides crucial insights into the varied perceptions of e-cigarettes among young adults. The results emphasize the need for targeted public health interventions and educational efforts to address this growing public health concern.

Perceived relative harm of e-cigarettes among Ukrainian adults

OBJECTIVES

Emerging evidence suggests that the use of safer nicotine products (SNPs), such as e-cigarettes and heated tobacco products (HTPs) poses significantly lower health risks than continued smoking, particularly over the short and medium term. However, it remains uncertain whether the public has been adequately informed about these relative risks. This study assesses the perceived relative harm of e-cigarettes compared to conventional cigarettes in Ukraine.

METHODS

Two nationally representative surveys were conducted in February 2021 and December 2022. Participants, irrespective of their smoking status, were asked whether they agreed with the statement that "using e-cigarettes is more harmful than smoking conventional cigarettes". The surveys also included questions about tobacco product usage, the most dangerous substances in cigarettes, and smoking cessation methods. The data were statistically analysed by deriving design-based weighted point estimates and 95% confidence intervals for the proportions within each response category.

RESULTS

In 2022, 38.1% (95% CI: 35.3-40.9) of adults believed that e-cigarettes were more harmful than cigarettes and the perception of relative harm remained relatively unchanged between the two surveys. Furthermore, 56.2% (95% CI: 50.0-62.2) of current cigarette smokers agreed with this statement, while only a small percentage of vapers (e-cigarette users) 7.4% (95% CI: 1.5-30.0) perceived e-cigarettes as more harmful than conventional cigarettes. Among non-smokers and dual users the share was 33.4% (95% CI: 30.0-36.9) and 32.7% (95% CI: 25.1-41.5), respectively.

CONCLUSION

Our findings indicate that in Ukraine the perception that e-cigarettes are more harmful than cigarettes, or the lack of knowledge regarding relative risks, prevails. This highlights the importance of accurate risk communication to promote a harm reduction approach to tobacco use.

Perceptions of harmfulness of heated tobacco and nicotine vaping products compared to cigarettes, and the association of advertising exposure on harm perceptions among adults who smoke in South Korea: Cross-sectional findings from the 2020 ITC Korea Survey

INTRODUCTION

Heated tobacco products (HTPs) and nicotine vaping products (NVPs) both are legal consumer products in the Republic of Korea. Little is known about perceptions of harmfulness of HTPs and NVPs relative to cigarettes in South Korea among adults who smoke, and how exposure to marketing may be associated with harmfulness perceptions.

METHODS

This study used data from the 2020 International Tobacco Control (ITC) Korea Survey, and included 3713 adult (aged 19 years) cigarette smokers who were: 1) exclusive smokers (n=1845); 2) dual HTP + cigarette consumers (n=1130); 3) dual NVP + cigarette consumers (n=224); and 4) triple consumers (all three products, n=514). Weighted multinomial regression models were conducted to estimate smokers' perceptions of harmfulness of HTPs and NVPs compared to cigarettes, NVPs to HTPs, and self-reported exposure to HTP/NVP advertising. Analyses compared the perceptions of harmfulness between the four different consumer groups, and tested whether exposure to HTP/NVP advertising was associated with perceptions of lower relative harm.

RESULTS

Among all respondents, 27.5% believe that HTPs are less harmful than cigarettes and 23.4% believe that NVPs are less harmful than cigarettes. Exclusive cigarettes smokers were significantly less likely to perceive that HTPs and NVPs are less harmful than cigarettes compared to dual HTP + cigarette consumers, dual NVP + cigarette consumers, and triple consumers (all p<0.001). Half of respondents perceive NVPs as equally harmful as HTPs (14.1% perceive NVPs as more harmful than HTPs). Exposure to HTP/NVP advertising was associated with perceiving these products as less harmful than cigarettes.

CONCLUSIONS

About one-quarter of Korean cigarette smokers perceive HTPs and NVPs as less harmful than cigarettes. Further investigation is required to understand how harm perceptions and HTP/NVP advertising are related to changes in product use, such as switching between products, using multiple products, or discontinuing all product use.

Smokers' support for the ban on sale of slim cigarettes in six European countries: findings from the EUREST-PLUS ITC Europe Surveys

Background: Efforts to regulate tobacco products and reduce consumption in the European Union (EU) include the European Tobacco Products Directive (TPD), which went into force in May 2016. Despite the initial discussion to include a ban on sale of slim cigarettes, it was excluded in the final TPD. The main goal of this study was to examine support for a ban on slim cigarettes among smokers in six European Countries. Methods: Data from the 2018 (Wave 2) International Tobacco Control Policy Evaluation Project 6 European Country (ITC 6E) EUREST-PLUS project survey, a cross sectional study of adult smokers (n=5592) from Germany, Greece, Hungary, Poland, Romania, and Spain, was analysed. Descriptive statistics were used to estimate support for a ban on slim cigarettes by sociodemographic characteristics and smoking behaviors. Logistic regression analysis was used to examine factors associated with support for a ban on slim cigarettes and perceptions of harm. Results: Support for a ban on slims varied across countries, with highest support in Romania (33.8%), and lowest in Greece (18.0%). Female smokers (OR=0.78; 95%CI=0.67-0.91, daily smokers (OR=0.68; 95%CI=0.47-0.97), menthol smokers (OR=0.55; 95%CI=0.36-0.86), and smokers who did not have plans to quit within next six months (OR=0.45; 95%CI=0.36-0.56) had significantly lower odds of supporting a ban on slim cigarettes. Overall, 21% of smokers perceived slim cigarettes as less harmful than regular cigarettes. Conclusions: Support for a ban of slim cigarettes was relatively low among smokers, while misperceptions that slim cigarettes are less harmful is high, particularly among countries where slim cigarette use is more prevalent. Findings support a ban on slim cigarettes to reduce misperceptions around slim cigarettes being less harmful.

Effects of providing tailored information about e-cigarettes in a digital smoking cessation intervention: randomized controlled trial

The effectiveness of e-cigarettes in smoking cessation is under debate. Informing smokers who are motivated to quit smoking about e-cigarettes may help them to make an informed decision about their use for smoking cessation, which, however, may also lead to unintended effects such as less quitting. This experimental study assessed the influence of providing tailored information about e-cigarettes in a web-based tailored smoking cessation intervention on participants' decision-making and smoking behavior. Adult smokers (N = 331) were randomized into a personalized eHealth intervention on (i) smoking cessation (control condition) or (ii) smoking cessation and information about e-cigarettes (intervention condition). Directly postintervention, participants in the intervention condition had more knowledge about e-cigarettes than participants in the control condition. Attitudes toward e-cigarettes were more positive among intervention participants than control participants, but the differences in attitude were less pronounced than the differences in knowledge and not consistent across items. At a 6-month follow-up, no between-condition differences were observed in the use of e-cigarettes as a smoking cessation method, the number of tobacco cigarettes smoked in the past 7 days, or other smoking outcomes.

'95% less harmful'? Exploring reactions to quantitative modified risk claims for snus and e-cigarettes

OBJECTIVES

Studies examining perceptions of 'modified risk tobacco product' (MRTP) messages for e-cigarettes and smokeless tobacco have indicated consumers want statistics and quantification of harm reduction. However, limited research exists on reactions to quantitative MRTP messages.

DESIGN

We conducted 12 focus groups in the USA in 2019-6 focused on e-cigarette messages and 6 on snus messages. Eight groups were with current smokers (ages 21-66) and four with young adult (ages 18-25) non-smokers (n=57). Participants discussed messages stating that use of snus and vaping products have been estimated by scientists to be about 90% and 95% less harmful than smoking cigarettes, respectively.

RESULTS

Several participants agreed the messages strongly communicated that the products are less harmful than cigarettes, were attention getting and could be 'convincing'. However, participants expressed scepticism about the source and accuracy of the stated figures, and some noted the claims could be misleading and attractive to young people. Comments also reflected some claim misunderstandings (eg, that e-cigarettes only pose a 5% chance of harm). Participants also agreed that stating e-cigarette risks 'are unlikely to exceed 5% of cigarette smoking harms' was confusing and less impactful than the '95% less harmful' wording.

CONCLUSIONS

Quantitative claims suggesting high levels of reduced risk when comparing e-cigarettes or smokeless tobacco/snus relative to cigarettes may be successful in gaining attention and being persuasive for some audiences, particularly, if from more credible sources. However, message developers, users and evaluators should be mindful of message limitations and aim to mitigate unintended consequences.

Smoking cessation behaviors and reasons for use of electronic cigarettes and heated tobacco products among Romanian adults

We report cessation behaviors, reasons for use of electronic cigarettes (EC) and heated tobacco products (HTP) and association of their use with quit attempts and smoking intensity using Romania Global Adult Tobacco Survey 2018. Weighted estimates of EC and HTP by cigarette smoking (CS) status were assessed. Quit attempts, intention to quit, reasons for lack of intention to quit among current CS, and reasons for current use of EC and HTP were estimated. The association of 'ever use' of EC and HTP with cigarette smoking intensity and quit attempts was explored using binary logistic regression. Of the total 4571 surveyed, 1243 (27.3%) were current CS, 300 (24.4%) made quit attempts in the past 12 months. Only 38 (12.5%) and 26 (8.6%) had used EC and HTP as an aid to quit. Among current CS, 512 (41.2%) had no intention to quit. Reasons for this were, 'enjoy smoking' (86.1%), 'reduce stress' (65.9%), and 'staying alert' (46.3%). Awareness and use of EC and HTP were significantly higher among current CS. 'Dual use' of EC and HTP with CS was manifolds higher than stand-alone use. Reasons for current use of EC and HTP were 'enjoyment', and 'use in places where smoking was prohibited'.

Combustible tobacco age-of-sale laws: an opportunity?

This editorial argues for the benefits of raising age-of-sale laws for combustible tobacco only, such as through a Combustible 21 law that would prohibit the sale of combustible tobacco to individuals under 21 years of age but leave open the opportunity to legally purchase e-cigarettes and smokeless tobacco products.

Risk Factors and Perceptions of E-Cigarette Use Among Selected Users in Johannesburg, South Africa

There is little scientific knowledge about e-cigarette use in South Africa. This study aimed to describe the risk factors and perceptions of selected Johannesburg-based users of e-cigarettes. A self-administered questionnaire was used to collect data from a convenient sample of 188 participants, of which 160 were males and 28 females. The survey results showed that participants used e-cigarettes at home (n = 28/ 14.8%), work (n = 76/ 40.4%), tertiary institutions (n = 50/ 26.5%) and in their vehicles (n = 24/ 12.7%), while (n = 96/ 51%) used the product in the presence of children. 57 participants (30.3%) started using e-cigarettes as a smoking cessation strategy, while 46 (24.4%) used it to manage smoking cravings. Most participants believed that e-cigarettes are addictive (n = 156/ 82.9%) and unhealthy (n = 139/ 73.9%). This study highlights the need and opportunity to improve public health action in the prevention and management of risks posed by e-cigarette products to users and non-users.