How do consumers perceive differences in risk across nicotine products? A review of relative risk perceptions across smokeless tobacco, e-cigarettes, nicotine replacement therapy and combustible cigarettes

Associations of educational and marketing messages with beliefs about nicotine and reduced nicotine cigarettes

INTRODUCTION

Widespread misperceptions about nicotine may have unintended effects on public health. We examined associations between existing messages about nicotine or tobacco and beliefs about nicotine and reduced nicotine cigarettes (RNC).

METHODS

2962 U.S. 18-45-year-olds were randomized in a May 2022 web-based survey to view one of 26 text-based messages about tobacco or nicotine from three sources: ongoing research (n = 8), messages authorized by FDA for VLN cigarettes (n = 6), and FDA's "From Plant to Product to Puff" campaign (n = 12); six messages from FDA's campaign did not reference nicotine and were treated as the reference source. Analyses examined associations between messages, grouped by source and individually, with beliefs about nicotine and RNC addictiveness and harms.

RESULTS

Relative to FDA messages that did not reference nicotine, all message sources were associated with greater odds of a correct belief about nicotine (Odds Ratios [ORs] = 1.40-1.87, p's < 0.01); VLN messages were associated with greater correct beliefs about RNC addictiveness (b = 0.23, p < .05). No campaign produced greater correct beliefs about RNC harms. At the individual level, only five messages were associated with a correct belief about nicotine (ORs = 2.12-2.56, p-values < .01), and one with correct beliefs about RNC harms (b = 1.09, p < .05), vs. the reference message.

CONCLUSIONS

Few existing messages improved understanding of the risks of nicotine separately from the risks of combustible products. Communication research is needed to promote greater public understanding of nicotine while minimizing unintended effects on nicotine and tobacco use.

Regional insights on tobacco-related tweets: unveiling user opinions and usage patterns

Introduction

Tobacco consumption and its impact on health remain high worldwide. Additionally, it is a contentious issue generating significant controversy. Twitter has proven to be a useful platform for evaluating public health topics related to population health behaviors, and tobacco consumption.

Objective

The objective of this study is to analyze the content of tweets related to tobacco. Moreover, geolocation data will be considered to understand regional differences.

Methods

Tweets published between 2018 and 2022, in both English and Spanish, containing the keyword "tobacco," were analyzed. A total of 56,926 tweets were obtained. The tweets were classified into different categories. 550 tweets were manually analyzed, and an automated and computerized classification was performed for the remaining and largest subset of tweets.

Results

The analysis yielded 30,812 classifiable tweets. Healthcare professionals were the most frequent contributors to the topic (50.2%), with the most common theme being general information about the toxic effects of tobacco. 57.9% of the tweets discussed the harmful effects of tobacco on health, with fear being the predominant emotion. The largest number of tweets were located in America.

Conclusions

Our study revealed a substantial number of tweets highlighting the health risks and negative perceptions of tobacco consumption. Africa showed the lowest percentage of tweets discussing the health risks associated with tobacco, coinciding with the continent having the least developed anti-tobacco policies. Healthcare professionals emerged as the most prominent users discussing the topic, which is encouraging as they play a crucial role in disseminating accurate and scientific health information.

Longitudinal impact of perceived harm and addiction on e-cigarette initiation among tobacco-naïve youth: Population Assessment of Tobacco and Health study (Waves 1-5)

OBJECTIVES

This study investigates the effect of e-cigarette-related harm and addiction perceptions on e-cigarette initiation among US tobacco-naïve adolescents.

STUDY DESIGN

This is a longitudinal study.

METHODS

Using data from five waves (2013-2019) of the Population Assessment of Tobacco and Health Study, we created a longitudinal data set for 2775 youth aged 12-17 years who had no prior use of tobacco products at Wave 1. E-cigarette initiation was defined as transitioning from non-use at Wave 1 to ever use in subsequent waves. Kaplan-Meier survival and Cox proportional hazard regression models were used to assess the impact of harm and addiction perceptions on e-cigarette initiation.

RESULTS

Our analytic sample comprised 63.1% of youth who had never used tobacco products at Wave 1 and consequently initiated e-cigarette use in subsequent waves. Over time, fewer individuals perceived e-cigarettes as harmless (14.1%-2.1%), whereas more perceived them as likely to cause addiction (53.7%-76.6%). Compared with perceiving e-cigarettes as a lot of harm, those perceiving some harm (adjusted hazard ratio [aHR] = 1.30, 95% confidence interval [CI]: 1.12-1.52), little harm (aHR = 1.42, 95% CI: 1.20-1.68), or no harm (aHR = 2.09, 95% CI: 1.64-2.65) were more likely to initiate e-cigarette use. Demographic factors for initiation included being Black or Hispanic ethnicity (vs White), younger age (12-14 vs15-17 years), and receiving over $20 per week (vs $0) in pocket money, with P-values <0.05. However, in adjusted results, addiction perceptions did not significantly impact e-cigarette initiation (P-values >0.05).

CONCLUSIONS

Among youth without prior tobacco/nicotine use, perceiving e-cigarettes as having low harm significantly predicted initiation over time. Effective prevention strategies, including targeted risk communication interventions, are essential for discouraging e-cigarette use among youth.

Reducing attractiveness of e-liquids: proposal for a restrictive list of tobacco-related flavourings

OBJECTIVE

Electronic cigarettes are addictive and harmful, and flavour is a key factor determining their abuse liability. Both adult smokers and young non-smokers like sweet and fruity flavours in particular. In order to discourage e-cigarette use among youth, the Dutch government announced in 2020 to only allow tobacco flavours in e-liquids. We propose a restrictive list of flavourings that will only enable the production of e-liquids with a tobacco flavour.

METHODS

We used e-liquid ingredient data notified via the European Common Entry Gate system before the government's announcement. First, we classified all e-liquids into flavour categories, and continued with the set of flavourings present in tobacco e-liquids. Five selection criteria related to prevalence of use, chemical composition, flavour description and health effects were defined to compile a restrictive list of tobacco flavourings.

RESULTS

E-liquids marketed as having tobacco flavour contained 503 different flavourings, some with tobacco flavour, but also other (such as sweet) flavours. We excluded (1) 330 flavourings used in <0.5% of e-liquids, (2) 77 used less frequently in tobacco than in all e-liquids, (3) 13 plant extracts, (4) 60 that are sweet or not associated with a tobacco flavour and (5) 7 flavourings with hazardous properties. This resulted in a final list of 16 flavourings.

CONCLUSIONS

Implementing this restrictive list will likely discourage e-cigarette use among youth, but could also make e-cigarettes less attractive as smoking cessation aid.

Testing messaging strategies to correct beliefs about nicotine and relative harm perceptions of non-cigarette tobacco products compared to cigarettes: A 2 × 2 factorial experiment of factsheets

INTRODUCTION

The misperception that nicotine is a major cause of cancer is common and may relate to inaccurate relative harm perceptions about tobacco products. To assess if messaging can correct these misperceptions, we tested factsheets that manipulated presences vs absence of (1) a causal alternative (i.e., combustion, not nicotine, causes disease) and/or (2) a reason for the misinformation (i.e., nicotine is the focus of many health messages).

METHODS

We used an online 2 × 2 factorial experiment of n = 193 adults who smoke and believe nicotine causes cancer to assess the effect of different message strategies on perceptions of tobacco products and switch intention. Pre-post differences and between-condition differences were assessed.

RESULTS

Strength of agreement with the statement that nicotine is a major cause of cancer decreased and switch intentions increased after message exposure. The proportion of participants with low relative harm perceptions increased for e-cigarettes and smokeless tobacco (p <.0001) and decreased for very low nicotine cigarettes compared to cigarettes. The message with both strategies decreased agreement that nicotine causes cancer more than the message with only the causal alternative. There was no significant effect of condition on relative harm beliefs or switch intentions.

CONCLUSIONS

Messages with both corrective strategies can reduce the belief that nicotine causes cancer to a greater extent than messaging that only contains a causal alternative. Belief accuracy increased after any message exposure, but these findings should be interpreted cautiously given the study design. Combined strategies should be further investigated in larger samples.

Expanding local sales restrictions on flavoured tobacco products to include menthol: retail sales changes in two Minnesota cities

BACKGROUND

In 2018, Minneapolis and St. Paul, Minnesota, expanded existing local sales restrictions on flavoured (non-menthol/mint/wintergreen) tobacco products ('flavour policies') to include menthol/mint/wintergreen-flavoured tobacco products ('menthol policies'). All policies included exemptions for certain store types.

METHODS

We obtained weekly retail tobacco product sales for 2015 through 2019 from NielsenIQ for convenience stores and other outlets in the policy jurisdictions and two comparison areas (rest of the state of Minnesota and total USA). We standardised unit sales across product categories and used NielsenIQ-provided descriptors to classify products as menthol (including mint/wintergreen) or flavoured (non-menthol/non-tobacco). Using single group interrupted time series models, we analysed unit sales by product category and by flavour separately for each geography to assess associations between menthol policy implementation and trends in tobacco product unit sales.

RESULTS

Following menthol policy implementation, unit sales of menthol cigarettes and menthol smokeless tobacco decreased in both cities, with smaller decreases in comparison areas. Flavoured cigar sales-which decreased following the flavour policies-further decreased after the menthol policies, while sales of menthol electronic nicotine delivery systems (ENDS) increased in both cities and sales of flavoured ENDS increased in St. Paul.

CONCLUSION

Expanding flavour policies to include menthol/mint/wintergreen was associated with significant decreases in unit sales of most menthol products and in total unit sales by tobacco product category. Increases in menthol and flavoured ENDS sales in these cities may be associated with legal sales by exempted retailers and/or illicit sales by non-compliant retailers, highlighting opportunities for retailer education and enforcement.

Tobacco-Free Nicotine Pouches and Their Potential Contribution to Tobacco Harm Reduction: A Scoping Review

Tobacco harm reduction (THR) refers to strategies designed to reduce the health risks associated with tobacco smoking but may involve continued use of nicotine and/or tobacco. Next-generation products (NGPs) are a THR alternative as they do not burn tobacco or produce smoke and deliver nicotine and have fewer and substantially lower levels of harmful chemicals compared to cigarettes. Tobacco‑free nicotine pouches (TFNPs) are an emerging category of nicotine‑containing oral products that do not combust or contain tobacco leaf. Similar to Swedish snus, TFNPs are placed between a user's lip and gum, and nicotine is absorbed through the oral mucosa rather than being inhaled. The aim of this scoping review was to systematically collate and evaluate published scientific evidence (cut‑off of 31 May 2023) identified from bibliometric databases investigating the potential of TFNPs to contribute to THR. Overall, studies examining chemical constituents indicated that the use of TFNPs may result in lower exposure to toxicants than other tobacco or nicotine-containing products, both combustible and non‑combustible. This reduction in toxicant exposure has been demonstrated by multiple human biomarker studies and in vitro toxicological assessments to translate to harm reduction potential in smokers switching to TFNPs. However, further study is warranted. At present, there is some evidence from human behavioral research that TFNPs can support either transitioning away from smoking or reducing cigarette consumption. Furthermore, TFNP use appears very much limited to current users of traditional tobacco products, and youth uptake has been limited. In conclusion, the findings of this review indicate that TFNPs have the potential to support THR efforts and may help inform evidence‑based regulation.

Changes in smoking patterns and characteristics of Koreans using the Korea National Health and Nutrition Examination Survey 2013-2021 data

OBJECTIVES

This study explored factors related to Korean adults' smoking patterns and also the reasons for using new types of tobacco products.

STUDY DESIGN

Cross-sectional survey.

METHODS

Data from the Korea National Health and Nutrition Examination Survey from 2013 to 2021 were used. The prevalence of the use of electronic cigarettes (e-cigarettes) or heated tobacco products (HTPs) alone or in combination with conventional cigarettes (CC) and the reasons for using new tobacco products are presented. Factors associated with using new types of tobacco products alone or in combination with CC compared to exclusive CC users were identified using multinomial logistic regression analysis.

RESULTS

The prevalence of current smoking was 25.54% in 2013 and 23.05% in 2021, with no significant change. The prevalence of CC decreased from 23.39% in 2013 to 15.77% in 2021. The prevalence of new tobacco use in combination with CC did not show a definite trend. The prevalence of exclusive use of new tobacco was <1% until 2018 and has rapidly increased thereafter. Of the HTPs users, 46.68% responded with 'no cigarette smell' as the main reason for HTPs use, followed by 'It seems less harmful than cigarette' (19.19%), and 'It seems to be helpful for quitting smoking' (15.04%). Of the e-cigarette users, 45.19% responded 'It seems to be helpful for quitting smoking' as the main reason for e-cigarette use, followed by 'It is less harmful than cigarettes' (19.98%). Compared to CC users, new tobacco users were younger, had a higher household income or education, and used more nutritional supplements.

CONCLUSION

Regulations for newer tobacco products are more lenient than for traditional cigarettes, leading to misunderstandings, especially among women and young people. To increase awareness of the risks of these products, specific policies such as disclosure of ingredients, ban on online sales, and increase in consumption tax, are needed.

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, intentions, and actual use of a consumer nicotine gum

BACKGROUND

Little is known about perceptions, use intentions, and behaviors of adults regarding nicotine gum that is marketed and regulated as a consumer product rather than as a medicinal nicotine replacement therapy (NRT).

METHODS

Survey data were collected from a Qualtrics online panel (N = 1000) of adults who had never used a consumer nicotine gum, recruited based on smoking behavior, and from current and former purchasers of one commercially available nicotine gum product (LUCY Chew and Park), recruited via emails to a customer database (N = 500). In addition to descriptive cross-sectional analyses, logistic regression was used to estimate the probability of intent to try and of product appeal among these different groups.

RESULTS

Among online panel respondents, individuals who smoked with and without plans to quit showed high intention to try the product (odds ratios 15.6 [95% CI 9.3, 27.6] and 9.8 [95% CI 5.8, 17.3] respectively, compared to people who formerly smoked) and persons who had never smoked showed low intentions to try. These results stood regardless of flavor. Among current and former purchasers of the study product, 43.4% of persons who had smoked cigarettes regularly indicated they were motivated to try the product "to help me quit smoking." Only 0.6% of young adult consumers of the nicotine gum (aged 21-30) had not tried tobacco products previously.

CONCLUSIONS

Consumer nicotine gum does not appear to attract those who have never used a tobacco product and the results for young adults suggest minimal appeal to youth. The study product was used primarily by individuals who currently smoke and/or use e-cigarettes but who wished to quit or reduce consumption. These results suggest that a consumer nicotine gum may reduce harm by substituting for higher-risk products such as combustible cigarettes.

Individual and Conjoint Factors Associated With Beliefs About the Harmfulness of Nicotine Replacement Therapies Relative to Combustible Cigarettes Among People Who Smoke: Findings From the 2020 ITC Four Country Smoking and Vaping Survey

INTRODUCTION

This study examined individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies (NRTs) relative to combustible cigarettes (CCs).

AIMS AND METHODS

Data analyzed came from 8642 adults (≥18 years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n = 1213), Canada (n = 2633), England (n = 3057), and United States (n = 1739). Respondents were asked: "Compared to smoking cigarettes, how harmful do you think nicotine replacement products are?" Responses were dichotomized into "much less" versus otherwise for analysis using multivariable logistic regression models, complemented by decision-tree analysis to identify conjoint factors.

RESULTS

Percentages believing that NRTs are much less harmful than CCs were 29.7% (95% CI = 26.2% to 33.5%) in Australia, 27.4% (95% CI = 25.1% to 29.8%) in England, 26.4% (95% CI = 24.4% to 28.4%) in Canada, and 21.7% (95% CI = 19.2% to 24.3%) in the United States. Across all countries, believing nicotine is not at all/slightly harmful to health (aOR = 1.53-2.27), endorsing nicotine vaping products (NVPs) as less harmful than CCs (much less harmful: aOR = 7.24-14.27; somewhat less harmful: aOR = 1.97-3.23), and possessing higher knowledge of smoking harms (aOR = 1.23-1.88) were individual factors associated with increased odds of believing NRTs are much less harmful than CCs. With some country variations, these nicotine-related measures also interacted with each other and sociodemographic variables to serve as conjoint factors associated with the likelihood of accurate NRT relative harm belief.

CONCLUSIONS

Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.

IMPLICATIONS

This study demonstrates that despite past efforts to educate people who smoke about the harms of NRTs relative to CCs, misperceptions around the relative harmfulness of NRTs remain substantial. In all four studied countries, subgroups of people who smoke regularly who are misinformed about the relative harmfulness of NRTs, and who may be reluctant to use NRTs for smoking cessation can be reliably identified for corrective interventions based on their understanding of the harms related to nicotine, NVPs and smoking along with sociodemographic markers. The identified subgroup information can be used to prioritize and inform the development of effective interventions to specifically address the gaps in knowledge and understanding of the various subgroups identified. Our results suggest these may need to be tailored for each country.

Perceived threat and fear responses to e-cigarette warning label messages: Results from 16 focus groups with U.S. youth and adults

AIMS

A warning on e-cigarette packaging is one way the U.S. government can inform the public of known harms of e-cigarette use. Currently, the only required warning on these products is: "WARNING: This product contains nicotine. Nicotine is an addictive chemical." This exploratory study aims to inform potential future investigations and FDA decisions regarding alternative warnings that may generate fear in addition to being intentionally informational.

METHOD

Data were obtained from responses by 16 online focus groups with adult (N = 47, age range = 18-64) and youth (N = 32, age range 14-16) participants with various smoking and vaping experiences. We showed each focus group a set of hypothetical e-cigarette warning labels to determine how they respond to currently existing public statements that communicate information on the toxicity of ingredients in e-cigarettes, potential health risks, addiction to nicotine, and the uncertainty of the science regarding health effects of using these products. The focus group interviews were audio recorded and transcribed. Transcripts were subjected to a multiphase coding process to identify common response themes. Codes derived from the Extended Parallel Processing Model were then applied to understand impact of potentially fear-inducing language by warning category and age group.

RESULTS

For adults, all warnings-except those about addiction-gave rise to spontaneous danger control (intended) responses, such as quit intentions. Warnings highlighting cognitive and uncertain effects may be particularly promising for adult consumers of tobacco products because both gengerated danger control and response efficacy without evidence of fear control. However, responses also suggest that warnings risk discouraging some adults who use combustible cigarettes from transitioning to e-cigarettes for harm reduction. For youth, while evidence of response efficacy and danger control emerged among youth exposed to messages in all warning categories but one-addiction-unproductive reactions indicative of fear control were also prevalent among youth respondent across most warning types. On average, youth were more skeptical than adults about the harms of using e-cigarettes.

POLICY IMPLICATIONS

Implications of study findings for the development of future effective e-cigarette warning messages are explored.

Effect of harm perception on ENDS initiation among US adolescents and young adults: Longitudinal findings from the population assessment of tobacco and health (PATH) study, 2013-2018

BACKGROUND

This study investigates how ENDS harm perception influences ENDS initiation over time among US young people.

METHODS

Data were from the sample of the Population Assessment of Tobacco and Health (PATH) Study conducted from 2013 to 2018. The Cox proportional hazards regression models were used to assess the relationship between absolute (the perception of harm from ENDS only) and relative harm perception (ENDS' harm relative to cigarettes) and ENDS initiation among adolescents (12-17 years) and young adults (18-24 years) separately. Harm perception was assessed at the wave before ENDS initiation in a subsequent wave. Weighted results were reported.

RESULTS

Of the 11,633 adolescents and 5089 young adults from baseline, 17.1% and 25.5% initiated ENDS use across four waves, respectively. Among adolescents (HR=2.31; 95%CI: 1.95-2.73) and young adults (HR=1.97; 95%CI: 1.69-2.30), perceiving lower relative harm of ENDS significantly predicted ENDS initiation in subsequent waves. Among adolescents, perceiving lower absolute harm of ENDS (HR=2.18; 95%CI: 1.83-2.60) predicted ENDS initiation in subsequent waves. Additionally, adolescents and young adults who ever used any other tobacco products or alcohol and lived with anyone who used tobacco were more likely to initiate ENDS use.

CONCLUSIONS

Among a representative longitudinal cohort of adolescents and young adults who had never used ENDS at baseline, perceiving ENDS as reduced or low-harm products significantly predicted ENDS initiation in subsequent waves. These findings underscore the importance of ENDS harm perception and the central role of risk communication strategies that need to target those young people at particular risk of unwarranted ENDS use.

Impact of Smoking Status and Nicotine Dependence on Academic Performance of Health Sciences Students

Background

Smoking behavior has been associated with poor academic performance among adult students worldwide. However, the detrimental effect of nicotine dependence on several students' academic achievement indicators is still unclear. This study aims to assess the impact of smoking status and nicotine dependence on grade point average (GPA), absenteeism rate and academic warnings among undergraduate health sciences students in Saudi Arabia.

Methods

A validated cross-sectional survey was conducted, in which, participants responded to questions evaluated cigarette consumption, urge to consume and dependency, learning performance, days of absentees, and academic warnings.

Results

A total of 501 students from different health specialties have completed the survey. Of whom, 66% were male, 95% ranging between the age of 18-30 years old, and 81% reported no health issues or chronic diseases. Current smokers estimated to be 30% of the respondents, of which 36% revealed smoking history of 2-3 years. The prevalence of nicotine dependency (high to extremely high) was 50%. Overall, smokers had significantly lower GPA, higher absenteeism rate, and higher number of academic warnings when compared to nonsmokers (p<0.001). Heavy smokers demonstrated significantly less GPA (p=0.036), higher days of absences (p=0.017), and more academic warnings (p=0.021) compared to light smokers. The linear regression model indicated a significant association between smoking history (increased pack-per-year) and poor GPA (p=0.01) and increased number of academic warning last semester (p=0.01), while increased cigarette consumption was substantially linked with higher academic warnings (p=0.002), lower GPA (p=0.01), and higher absenteeism rate for last semester (p=0.01).

Conclusion

Smoking status and nicotine dependence were predictive of worsening academic performance, including lower GPA, higher absenteeism rate and academic warnings. In addition, there is a substantial and unfavorable dose-response association between smoking history and cigarette consumption with impaired academic performance indicators.

A Decision-Theoretic Public Health Framework for Heated Tobacco and Nicotine Vaping Products

Markets for nicotine vaping products (NVPs) and heated tobacco products (HTPs) have grown as these products became positioned as harm-reduction alternatives to combusted tobacco products. Herein, we present a public health decision-theoretic framework incorporating different patterns of HTP, NVP, and cigarette use to examine their impacts on population health. Our framework demonstrates that, for individuals who would have otherwise smoked, HTP use may provide public health benefits by enabling cessation or by discouraging smoking initiation and relapse. However, the benefits are reduced if more harmful HTP use replaces less harmful NVP use. HTP use may also negatively impact public health by encouraging smoking by otherwise non-smokers or by encouraging initiation or relapse into smoking. These patterns are directly influenced by industry behavior as well as public policy towards HTPs, NVPs, and cigarettes. While substantial research has been devoted to NVPs, much less is known about HTPs. Better information is needed to more precisely define the health risks of HTPs compared to cigarettes and NVPs, the relative appeal of HTPs to consumers, and the likelihood of later transitioning to smoking or quitting all products. While our analysis provides a framework for gaining that information, it also illustrates the complexities in distinguishing key factors.

E-Cigarettes and the Multiple Responsibilities of the FDA

This paper considers the responsibilities of the FDA with regard to disseminating information about the benefits and harms of e-cigarettes. Tobacco harm reduction advocates claim that the FDA has been overcautious and has violated ethical obligations by failing to clearly communicate to the public that e-cigarettes are far less harmful than cigarettes. We argue, by contrast, that the FDA's obligations in this arena are more complex than they may appear at first blush. Though the FDA is accountable for informing the public about the health risks and benefits of products it regulates, it also has other roles (and attendant responsibilities) that inform when and how it should disseminate information. In addition to being a knowledge purveyor, it is also a knowledge producer, an advisor to the public, and a practical agent shaping the material conditions in which people make health-related choices. In our view, those other roles call for caution in the way the FDA interprets and communicates the available evidence.

Challenges in Predicting the Change in the Cumulative Exposure of New Tobacco and Related Products Based on Emissions and Toxicity Dose-Response Data

Many novel tobacco products have been developed in recent years. Although many may emit lower levels of several toxicants, their risk in the long term remains unclear. We previously published a method for the exposure assessment of mixtures that can be used to compare the changes in cumulative exposure to carcinogens among tobacco products. While further developing this method by including more carcinogens or to explore its application to non-cancer endpoints, we encountered a lack of data that are required for better-substantiated conclusions regarding differences in exposure between products. In this special communication, we argue the case for more data on adverse health effects, as well as more data on the composition of the emissions from tobacco products. Such information can be used to identify significant changes in relevance to health using the cumulative exposure method with different products and to substantiate regulatory decisions.

Early adoption of heated tobacco products resembles that of e-cigarettes

BACKGROUND

Heated tobacco products (HTP) generate nicotine-containing aerosol by heating tobacco rather than burning it. The US Food and Drug Administration (FDA) has recently authorised the sale of one HTP brand, iQOS, in the USA. This study examined the awareness, use and risk perceptions of HTP in the USA following FDA authorisation.

METHODS

A national probability sample of 20 449 US adults completed an online survey between November 2019 and February 2020. In addition to assessing awareness and use of HTP, two ratios were calculated: the ratio of those who experimented with HTP given that they had heard about it (E/H) and the ratio of those who currently used HTP given experimentation (C/E). These ratios for HTP were compared against those for e-cigarettes from a similar national survey in 2012.

RESULTS

Overall, 8.1% of respondents had heard of HTP. Only 0.55% had tried and 0.10% were current users. The rate of experimentation among those who heard about HTP and the rate of current use among experimenters were, however, similar to those for e-cigarettes in 2012: E/H and C/E for HTP were 6.8% and 18.2%, respectively; and 10.7% and 17.8%, respectively for e-cigarettes. The majority of respondents considered HTP either less harmful than (11.6%), or equally harmful as e-cigarettes (42.7%).

CONCLUSIONS

Only a small fraction of US population in 2020 have tried any HTP. However, the similarity in early adoption rates following awareness, suggests that future adoption for HTP may be similar to that for e-cigarettes, if HTP are marketed more aggressively.

Beliefs and Characteristics Associated With Believing Nicotine Causes Cancer: A Descriptive Analysis to Inform Corrective Message Content and Priority Audiences

INTRODUCTION

Many cigarette smokers want to quit but have not. Switching to noncombustible products can reduce disease risk, but misperceptions that nicotine causes cancer might impact relative harm perceptions about noncombustible products and considering switching. Identifying which smokers are most likely to hold this misperception and associated beliefs can inform the content of and priority audiences for corrective messaging.

METHODS

Bivariable log binomial models were run on a sample of 9,013 adult established smokers from Wave 3 of the Population Assessment of Tobacco and Health. Post hoc testing identified groups and beliefs associated with significantly higher-than-average prevalence of the misperception.

RESULTS

About 61.2% of smokers believe nicotine causes cancer or don't know. Non-Hispanic Black (PR: 2.09) and Hispanic (PR: 1.73) smokers, as well as those making under $10,000 a year (PR: 1.36) had significantly higher-than-average prevalence of the misperception. Smokers who had recently used ENDS or smokeless tobacco had significantly lower-than-average prevalence of the misperception (PR: 0.70 and 0.63, respectively). Prevalence of nicotine misperceptions was significantly higher-than-average among those who recognized all ten smoking-caused diseases (PR: 1.34), believed additive-free cigarettes were more harmful than regular cigarettes (PR: 1.71), or did not report subjective norms supporting noncombustible use (PR: 1.05).

CONCLUSION

High perceived threat of tobacco may be overgeneralized to nicotine. High prevalence of the misperception among Non-Hispanic Black and low-income smokers is concerning, considering existing health disparities. Messaging should attempt to correct the misperception that nicotine causes cancer. Inferential reasoning after message exposure should assess accuracy of relative harm perceptions.

IMPLICATIONS

The current study supports the need for corrective messaging to address the misperception that nicotine causes cancer. Identifying that nicotine misperceptions are associated with higher harm perceptions about tobacco suggests that there may be unintended consequences of high perceived harm of tobacco that need to be addressed. As nicotine misperceptions are significantly more prevalent among those already at higher risk of tobacco caused diseases, care should be taken to ensure equity in message dissemination.

Charming e-cigarette users with distorted science: a survey examining social media platform use, nicotine-related misinformation and attitudes towards the tobacco industry

OBJECTIVE

To examine the role of social media in promoting recall and belief of distorted science about nicotine and COVID-19 and whether recall and belief predict tobacco industry beliefs.

DESIGN

Young adults aged 18-34 years (N=1225) were surveyed cross-sectionally via online Qualtrics panel. The survey assessed recall and belief in three claims about nicotine and COVID-19 and three about nicotine in general followed by assessments of industry beliefs and use of social media. Ordinal logistic regression with robust standard errors controlling for gender, race/ethnicity, education, current e-cigarette use and age was used to examine relationships between variables.

RESULTS

Twitter use was associated with higher odds of recall (OR=1.21, 95% CI=1.01 to 1.44) and belief (OR=1.26, 95% CI=1.04 to 1.52) in COVID-19-specific distorted science. YouTube use was associated with higher odds of believing COVID-19-specific distorted science (OR=1.32, 95% CI=1.09 to 1.60). Reddit use was associated with lower odds of believing COVID-19-specific distorted science (OR=0.72, 95% CI=0.59 to 0.88). Recall (OR=1.26, 95% CI=1.07 to 1.47) and belief (OR=1.28, 95% CI=1.09 to 1.50) in distorted science about nicotine in general as well as belief in distorted science specific to COVID-19 (OR=1.61, 95% CI=1.34 to 1.95) were associated with more positive beliefs about the tobacco industry. Belief in distorted science about nicotine in general was also associated with more negative beliefs about the tobacco industry (OR=1.18, 95% CI=1.02 to 1.35).

CONCLUSIONS

Use of social media platforms may help to both spread and dispel distorted science about nicotine. Addressing distorted science about nicotine is important, as it appears to be associated with more favourable views of the tobacco industry which may erode public support for effective regulation.

Risk perception of IQOS™ and cigarettes: Temporal and cross-country comparisons

Background

Risk perception (RP) is central to smokers’ decision to switch to smoke-free tobacco and nicotine products (TNP). This study assessed temporal trends in the health RP of a novel heated tobacco product, IQOS^TM, relative to cigarettes, among current IQOS^TM users.

Methods

The analyses included repeated cross-sectional data from online surveys in Germany (2018–19), Italy (2018–19), and Japan (2016–17, 2017–18, and 2018–19) among a random sample of current adult IQOS^TM users from local registers of IQOS^TM users. The health RPs of cigarettes and IQOS^TM were assessed using the ABOUT™–Perceived Risk instrument, and their difference was described as the relative RP of IQOS^TM to cigarettes (RP_Cig:IQOS^TM).

Results

After adjustment for covariates, the relative RP_Cig:IQOS^TM was higher in 2018 than in 2019 (0.93; standard error, 0.33; P = 0.005). This was driven by an increase in the RP of IQOS^TM over time in Italy (2018: 42.6 [95% CI, 41.6–43.5]; 2019: 44.4 [43.4–45.4]) and Japan (2017: 44.0 [43.1–44.9); 2018: 45.9 [45.2–46.7]; 2019: 48.6 [47.9–49.4]), while the RP of cigarettes remained stable.

Conclusions

The relative RP of IQOS^TM decreased over time, driven by an increase in the RP of IQOS^TM, in agreement with epidemiological studies indicating a temporal reduction in the relative RP of smoke-free TNPs. Continued surveillance of the RP of novel TNPs is warranted to inform effective TNP risk communication and ensure that adults smokers who would otherwise continue to smoke understand the relative risks of novel TNPs.

•

Risk perception is central to smokers' decision to switch from cigarettes.

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Little is known of temporal changes in risk perception of novel tobacco products.

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Risk perception of heated tobacco increased in Italy and Japan.

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Difference in risk perception of heated tobacco relative to cigarettes declined.

Perceived harm of heated tobacco products, e-cigarettes, and nicotine replacement therapy compared with conventional cigarettes among ever and current heated tobacco users

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Hungarian HTP users similarly perceive the harm of HTPs and NRT.

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Compared to CCs, HTP users perceive HTPs less harmful than of e-cigarettes.

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Current and exclusive HTP users more likely perceive HTPs as less harmful than CCs.

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HTP users have distorted harm perceptions of nicotine products.

Aims

There is limited knowledge on how ever and current heated tobacco product (HTP) users perceive the relative harm of various nicotine-containing products. The aim of this study was to explore relative harm perceptions of HTPs, e-cigarettes, and nicotine replacement therapy (NRT) relative to conventional cigarettes (CCs) among ever versus current HTP users, and exclusive (who use only a HTP) versus dual/poly-users (concurrent users of HTP and CCs and/or e-cigarettes).

Methods

Data came from 1423 ever or current Hungarian adult HTP users who participated in a cross-sectional web-based survey in 2020. Unadjusted and adjusted logistic regression analyses were performed to explore the associations between relative harm perceptions, HTP use patterns, past tobacco use, HTP dependence, and socio-demographic variables.

Results

81.2% of the sample was current HTP users, of them 78.4% were exclusive HTP users. Compared to CCs, 86.2% of the sample perceived HTP to be less harmful, with current and exclusive HTP users endorsing more this belief, followed by NRT (79.8%), and e-cigarettes (45.2%). In general, neither socio-demographic variables nor past tobacco use, HTP use pattern, and HTP dependence were related to perceived harmfulness across the tested products. However, there was a specific pattern for each tested product with a set of explanatory variables.

Conclusions

Ever/current HTP users presented misperceptions about the harms of HTPs, e-cigarettes, and NRT. They underestimated the potential health benefits of NRT and had distorted harm perceptions about HTPs and e-cigarettes. Public education about the relative harms of different nicotine and tobacco products is urgently needed.

Do smokers' perceptions of the harmfulness of nicotine replacement therapy and nicotine vaping products as compared to cigarettes influence their use as an aid for smoking cessation? Findings from the ITC Four Country Smoking and Vaping Surveys

Introduction

This study examined whether smokers’ harm perceptions of nicotine replacement therapy (NRT) and nicotine vaping products (NVPs) relative to cigarettes predicted their subsequent use as smoking cessation aids during their last quit attempt (LQA).

Aims and Methods

We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the United States. We used multinomial logistic regression models to examine prospective associations between harm perceptions of (a) NRT and (b) NVPs and their use at LQA, controlling for socio-demographic and other potential confounders.

Results

Smokers who perceive that (a) NRT and (b) NVPs are much less harmful than cigarettes were more likely to subsequently use the respective product as an aid than using no aid or other aids during LQA (adjusted relative risk ratio [aRRR] = 3.79, 95%CI = 2.16–6.66; and aRRR = 2.11, 95%CI = 1.29–3.45, respectively) compared to smokers who perceive these products as equally or more harmful. Additionally, those who perceive NVPs as much less harmful than cigarettes were less likely to use NRT as a quit aid (aRRR = 0.34, 95%CI = 0.20–0.60). No country variations for these associations were found.

Conclusions

This study found that smokers’ perceptions of the harmfulness of (a) NRT and (b) NVPs relative to cigarettes predicted the respective product use when trying to quit smoking. Corrective education targeting misperceptions of nicotine products’ relative harmfulness may facilitate their use for smoking cessation.

Implications

Nicotine replacement therapy and nicotine vaping products are two commonly used smoking cessation aids. This study demonstrates that misperceptions of the harms of nicotine products relative to cigarettes influence their use for smoking cessation. Believing that nicotine vaping products are much less harmful than cigarette smoking may lead some smokers to prefer these products over nicotine replacement therapy to aid smoking cessation. Education targeting misperceptions of nicotine products’ harmfulness relative to cigarettes may enable smokers to make informed choices about which are appropriate to aid smoking cessation.

Public support for further regulating smoking, snus and e-cigarettes in Norway, and its associations with risk perceptions and tobacco use

BACKGROUND

Public support is an indication of the legitimacy of governmental tobacco interventions. Little is known about what it is that shapes the support for various tobacco policy measures. We examine whether there are differences in public support for new measures against smoking, snus, and e-cigarettes in Norway, and whether public support is associated with user status and perceptions of the products' harm potential.

DATA AND METHODS

In December 2017, 4,002 people aged between 16 and 89 answered a web-based questionnaire. The sample was randomly drawn from Norstat's web panel, and pre-stratified by gender, age, region, and education in order to obtain an approximate country-representative sample. Respondents were asked to indicate their support for eight possible future measures to further restrict accessibility of tobacco (asked separately with regard to smoking tobacco, snus and e-cigarettes respectively), on a five-point scale from 1 = 'no support' to 5 = 'full support'. We utilized means and t-tests to address differences in support between measures. We then constructed sum scores to assess the total support for regulating each tobacco product and subjected these indexes to linear regression analyses, controlling for background variables.

RESULTS

For six of the eight proposed measures, public opinion is less supportive of e-cigarette regulations than of similar regulations for snus and, especially, smoking tobacco. In all three regression models, significant associations with risk perception, user status and gender were maintained after multiple controls. The associations with risk perceptions were stronger for support of snus and e-cigarette regulation than for smoking tobacco.

CONCLUSION

Overall, these findings illustrate the key role of risk perceptions in forming public opinions regarding tobacco-preventive regulations and underline the importance of information to ensure that population risk perceptions are accurate.

Evolution of tobacco products: recent history and future directions

Declines in cigarette smoking prevalence in many countries and the consolidation of the tobacco industry have prompted the introduction of other forms of nicotine delivery. These include electronic nicotine delivery systems (ENDS), heated tobacco products (HTPs) and oral nicotine products (ONPs). Evolving over time, some of these products now deliver nicotine at levels comparable to cigarettes and may serve as effective substitutes for smokers. However, certain products, especially ENDS like JUUL, have also appealed to youth and non-smokers, prompting concerns about expanding nicotine use (and potentially nicotine addiction). The tobacco industry could shift away from primarily promoting cigarettes to promoting ENDS, HTPs and/or ONPs, though at this time it continues to heavily promote cigarettes in low and middle-income countries. Differing regulatory regimes may place upward and downward pressures on both cigarettes and these newer products in terms of population use, and may ultimately drive the extent to which cigarettes are or are not displaced by ENDS, HTPs and/or ONPs in the coming decade.

Changes in harm perception of ENDS and their predictors among US adolescents: findings from the population assessment of tobacco and health (PATH) study, 2013-2018

Electronic nicotine delivery systems (ENDS) use has dramatically increased in the US. This study aimed to characterize changes in ENDS harm perception over time and associated predictors among US adolescents. Data from the 2013-2018 Population Assessment of Tobacco and Health Study (PATH) for adolescents (12-17 years) were utilized. Trend analyses were employed to delineate changes in comparative and absolute ENDS harm perception over a four-year interval. We applied a time-varying effect model (TVEM) to examine the associations between the changes in harm perception and associated predictors. The results suggest that perception of ENDS as less harmful than cigarettes significantly decreased from 54.3% at Wave 1 (2013) to 30.4% at Wave 4 (2018) (P < 0.001). Perception of ENDS as no or little harm decreased from 35.9% at Wave 1 to 16.9% at Wave 4 (P < 0.001). These changes in harm perception were less robust among males, adolescents who did not have positive tobacco-related attitudes, and those with smoke-free home rules (P's < 0.05). Additionally, having ever used ENDS or alcohol were more likely to be associated with reduced ENDS-related harm perception over time (P's < 0.05). Our results show that while ENDS-related harm perception have generally increased, this does not appear to be equally experienced across all adolescents, potentially highlighting the importance of at-risk groups and targets for intervention. This study can help identify individuals at risk of ENDS initiation because of their favorable ENDS harm perception profile, as well as guide the development of ENDS risk communication interventions for adolescents.

Association between perceived health risks of e-cigarettes and actual e-cigarette use, based on cigarette smoking status and sexual and gender minority status among U.S. adults

BACKGROUND

There is a lack of consensus in the literature about the association between the perceived health risks of e-cigarettes and their actual use, an association that may be based on cigarette smoking status or sexual and gender minority status. This study examined the moderating effect of these variables as well as differences in e-cigarette use between and within perceived harmfulness of e-cigarettes and cigarette smoking among U.S. adults.

METHODS

The data were drawn from the 2020 and 2019 Health Information National Trends Survey (HINTS 5), Cycles 4 and 3, on adults (N = 9303). We estimated weighted multivariable logistic regression models and conducted marginal analyses based on perceived harmfulness of e-cigarettes.

RESULTS

Of the study population, 30.75% currently used e-cigarettes daily or some days. No significant difference in e-cigarette use was found between sexual minorities and heterosexuals, but there was a significant interaction between sexual identity and perceived harmfulness of e-cigarettes. Compared to non-smokers, current daily or some days cigarette smokers were more likely to use e-cigarettes (AOR = 3.48, 95% CI = 1.25, 9.72). Those who perceived e-cigarettes to be just as harmful as actual cigarettes (AOR = 0.13, 95% CI = 0.06, 0.27) or more harmful (AOR = 0.03, 95% CI = 0.01, 0.10), or were uncertain (AOR = 0.18, 95% CI = 0.08, 0.45), were less likely to use e-cigarettes compared to those who perceived e-cigarettes to be less harmful. Former and current cigarette smokers who perceived e-cigarettes as less harmful had a higher probability of using e-cigarettes daily or some days than did non-cigarette smokers. For the current and former cigarette smoking groups, those who perceived e-cigarettes as less harmful had the highest probability of current e-cigarette use than did those who were uncertain or perceived e-cigarettes as just as harmful, whereas the probability was not significant for those who perceived e-cigarettes as more harmful.

CONCLUSION

Current daily or some days use of e-cigarettes is associated with current daily or some days cigarette smoking and lowered perceived harmfulness of e-cigarettes among the U.S. adult population. Tailored health promotion and intervention efforts may reduce the potential perceived health and behavioral/lifestyle risks related to the use of tobacco products, especially the use of e-cigarettes daily among former and current cigarette smokers as well as those who perceive e-cigarettes as less harmful.

The Dilemma of Correcting Nicotine Misperceptions: Nicotine Replacement Therapy versus Electronic Cigarettes

Many people overestimate the health risks associated with nicotine, mistakenly perceiving nicotine as the main carcinogen in cigarettes and a leading cause of smoking-related diseases. Health professionals have been calling for public education programs to correct nicotine misperceptions in the hope that a lower risk perception of nicotine could encourage the use of nicotine replacement therapy (NRT). However, a lower risk perception of nicotine could also lower perceived risk of electronic cigarettes (e-cigarettes). This paper evaluated the necessity of correcting nicotine misperceptions and explored possible intervention strategies to increase use of NRT and decrease use of e-cigarettes. In Study 1, smokers were surveyed about their perceptions of nicotine harm, and attitudes and intention toward using NRT and e-cigarettes. Results showed that overestimation of nicotine harm was associated with e-cigarette attitude and intention, but not with NRT. Informed by the survey results, three correction messages (a nicotine message, an NRT message, and an e-cigarette message) were developed and experimentally tested in Study 2 on both tobacco users and non-tobacco users. The nicotine message lowered people's perception of nicotine harm but it did not change attitude and intention toward tobacco product use. The NRT message also failed to influence NRT attitudes and intentions. The e-cigarette message significantly lowered attitudes and intentions to use e-cigarette.

Changes in knowledge, perceptions and use of JUUL among a cohort of young adults

OBJECTIVE

E-cigarettes have gained popularity, most recently with pod-style devices, such as JUUL. We examined changes in JUUL awareness, use, perceptions, nicotine content knowledge, number of days a pod lasts and exposure to JUUL retail advertising over a 6-month period in a cohort of young adults.

METHODS

In spring and fall 2018, 1836 young adults completed online surveys on tobacco use, including JUUL perceptions and use behaviours. Demographics, tobacco use and JUUL advertising exposure in spring 2018 were examined as predictors of current JUUL use in fall 2018.

RESULTS

Ever and current JUUL use doubled in 6 months (5.9% vs 12.7%, p<0.001; 1.6% vs 3.4%, p<0.001). The number of days a JUUL pod lasts significantly changed (p=0.049). Although there was an increase in those reporting JUUL has as much or more nicotine than a pack of cigarettes, 58% are 'not sure' of JUUL's nicotine content. Exposure to JUUL's advertising significantly increased (31.8% to 46.4%; p<0.001). In multivariable models, those perceiving JUUL as or more harmful than cigarettes, and former and never cigarette smokers had significantly lower odds of current JUUL use at 6 months compared with their respective counterparts (p<0.0001). Those reporting exposure to JUUL's advertising had significantly increased odds of current JUUL use 6 months later (p<0.03).

CONCLUSIONS

Findings demonstrate changes in knowledge of JUUL's nicotine content, perceptions and use over a short period of time, suggesting frequent measurement is necessary. Additionally, efforts are needed to regulate retail advertising and ensure consumer education about product risks as they are associated with current use.

Responses to reduced nicotine cigarette marketing features: a systematic review

OBJECTIVE

To systematically review the literature regarding responses to commercial and public health marketing features for reduced nicotine cigarettes (RNCs) to anticipate potential industry and regulatory actions should an RNC product standard be issued.

DATA SOURCES

We searched PubMed for English-language articles using several keywords for reduced nicotine products, cigarettes and marketing features published through 2020.

STUDY SELECTION

Of 4092 records, 26 studies were retained for review that met criteria focusing on responses to RNC marketing features.

DATA EXTRACTION

Search terms created by the research team were used for review and included independent extraction and coding by two reviewers. Coding was categorised using study design terminology, commercial and public health features in tobacco regulatory science, and their association with individual responses outlined by several message processing outcomes.

DATA SYNTHESIS

Most studies focused on current cigarette smokers and were cross-sectional. Reactions to RNCs and attitudes and beliefs were the most common outcomes measured. For commercial features, articles generally studied RNC advertisements, products and/or descriptors. For public health features, articles studied counter-messaging (eg, warning labels) or general descriptors about nicotine or a reduced nicotine product standard. Commercial features were generally associated with favourable responses. Public health features offset favourable responses across most outcomes, though their efficacy was mixed. Contrasts in results by smoking status are discussed.

CONCLUSIONS

Commercial marketing of RNCs is appealing and may need stronger regulations or communication campaigns to accurately convey risks. Opportunities exist for future research within tobacco regulatory science.

Development and testing of relative risk-based health messages for electronic cigarette products

BACKGROUND

Health messages on e-cigarette packs emphasise nicotine addiction or harms using similar wording to warnings on cigarette packs. These may not be appropriate for e-cigarettes which constitute a reduced risk alternative for smokers. This research aimed to (1) develop and test a selection of relative risk messages for e-cigarette products; (2) compare these to the two current EU Tobacco Products Directive (TPD) nicotine addiction messages; and (3) explore differences between smokers, non-smokers and dual users.

METHOD

Twenty-six messages focusing on either harm-reduction or cessation were developed and rated by multidisciplinary experts for accuracy, persuasiveness and clarity. The eight highest ranking messages were compared alongside the TPD messages in a sample of 983 European residents (316 smokers, 327 non-smokers, 340 dual users) on understandability, believability and convincingness.

RESULTS

On all three constructs combined, the two TPD messages rated the highest, closely followed by four relative risk messages "Completely switching to e-cigarettes lowers your risk of smoking related diseases", "Use of this product is much less harmful than smoking", "Completely switching to e-cigarettes is a healthier alternative to smoking", and "This product presents substantially lower risks to health than cigarettes" which did not differ statistically from the TPD messages. Non-smokers rated TPD1 significantly higher overall than dual users. Dual users rated "This product is a safer alternative to smoking" significantly higher than non-smokers. Messages did not differ on understandability.

CONCLUSIONS

These alternative messages provide a useful resource for future research and for policy makers considering updating e-cigarette product labelling.

Perception of Harmfulness of Various Tobacco Products and E-Cigarettes in Poland: A Nationwide Cross-Sectional Survey

Perceptions of the harmfulness of tobacco products may be a determinant of smoking behaviors. This study aimed to: (1) assess the perception of harmfulness of various tobacco products and e-cigarettes in Poland as well as (2) to assess the awareness of the health effects of using tobacco and e-cigarettes. A cross-sectional survey was conducted in 2019 with a nationally representative sample of 1011 individuals aged 15 and over. In the studied group, 22.3% were smokers. Smokeless tobacco was most likely to be perceived as less harmful than cigarettes (25%), followed by water pipe (24.5%), heated tobacco products (22%), e-cigarettes (21.6%), slim cigarettes (17.1%), flavored cigarettes (except menthol ones) (16.1%), menthol cigarettes (15.6%) and cigarillos (12.6%). In this study, 10% of respondents denied that smoking causes serious diseases. Most of the respondents (88.9%) were aware that smoking causes lung cancer (88.9%), but only 70.4% were aware that smoking causes stroke. Smokers compared to non-smokers were less likely to declare that smoking causes a stroke (OR: 0.43, 95%CI: 0.31–0.59; p < 0.001) or myocardial infarction (OR: 0.41, 95%CI: 0.29–0.60; p < 0.001). There were no significant differences (p > 0.05) in the perception of harmfulness of various tobacco products and e-cigarettes by gender, age, or occupational status.

Knowledge and Beliefs Regarding Harm From Specific Tobacco Products: Findings From the H.I.N.T. Survey

PURPOSE

Determine whether dual tobacco users have different levels of knowledge about nicotine addiction, perceived harm beliefs of low nicotine cigarettes (LNCs) and beliefs about electronic cigarettes (e-cigarettes).

DESIGN

Quantitative, Cross-sectional.

SETTING

Health Information National Trends Survey 5 (Cycle 3, 2019).

PARTICIPANTS

Nationally representative adult non-smokers (n=3113), exclusive cigarette smokers (n=302), and dual (cigarette and e-cigarette) users (n=77).

MEASURES

The survey included single item measures on whether nicotine causes addiction and whether nicotine causes cancer. A five-point Likert scale assessed comparative harm of e-cigarettes and LNCs relative to conventional combustible cigarettes (1=much more harmful, 3=equally harmful…5 = much less harmful, or don't know).

ANALYSIS

We used weighted multiple linear regression model to estimate means and 95% confidence intervals (CI) of e-cigarettes and LNCs beliefs by current tobacco user status.

RESULTS

Over 97% of dual users, 83% of non-smokers and 86% of exclusive cigarette smokers correctly identified that nicotine is addictive. The majority of subjects incorrectly identified nicotine as a cause of cancer, with dual users having the lowest proportion of incorrect responses (60%). Dual users rated e-cigarette harmfulness as less harmful than combustibles (mean=2.20; 95% CI=1.73, 2.66) while exclusive cigarette smokers and non-smokers rated them as similarly harmful. LNCs were considered equally harmful and addictive as conventional cigarettes.

CONCLUSION

Dual users had a higher knowledge base of tobacco-related health effects. The effectiveness of policies or medical recommendations to encourage smokers to switch from cigarettes to LNCs or e-cigarettes will need to consider accurate and inaccurate misperceptions about the harm and addictiveness of nicotine. Improved public health messages about different tobacco products are needed.

Effects of tobacco product type and characteristics on appeal and perceived harm: Results from a discrete choice experiment among Guatemalan adolescents

Guatemala is one of the few countries where both heated tobacco products (HTPs) and electronic cigarettes (e-cigarettes) remain unregulated. We used a discrete choice experiment (DCE) administered to 2038 high school students to assess how tobacco product attributes influence their appeal among Guatemalan adolescents. Participants were randomly assigned to evaluate 4 of 32 contrasting sets, each containing 3 packs (1 of each product type). Experimental manipulations included: product type, brand, nicotine content and flavor. Participants then indicated which product they were most and least interested in trying and would be most and least harmful to their health. Conditional logistic regression models were used to assess the impact of product characteristics on choice. Product type accounted for almost 90% of variation in choices. Respondents were less interested in trying HTPs (B = -0.93; p < 0.001) and viewed them as more harmful (B = 2.77; p < 0.001) compared to cigarettes. They were more interested in trying e-cigarettes (B = 1.22; p < 0.001), which were also perceived as less harmful (B = -1.47; p < 0.001) compared to cigarettes. Products without nicotine were of more interest for trying (B = 0.14; p < 0.001) and perceived as more harmful (B = 0.20; p < 0.001) than those with. Students were more interested in trying a flavor compared to regular tobacco and among the flavors, berry was the highest rated one (B = 0.28; p < 0.001). Finally, in this country with weak tobacco control, e-cigarettes appear to be more appealing and perceived as less harmful than HTPs and cigarettes. Packaging and flavoring regulations are urgently needed on these products as they are a marketing strategy targeting adolescents.

Topics of Nicotine-Related Discussions on Twitter: Infoveillance Study

BACKGROUND

Cultural trends in the United States, the nicotine consumer marketplace, and tobacco policies are changing.

OBJECTIVE

The goal of this study was to identify and describe nicotine-related topics of conversation authored by the public and social bots on Twitter, including any misinformation or misconceptions that health education campaigns could potentially correct.

METHODS

Twitter posts containing the term "nicotine" were obtained from September 30, 2018 to October 1, 2019. Methods were used to distinguish between posts from social bots and nonbots. Text classifiers were used to identify topics in posts (n=300,360).

RESULTS

Prevalent topics of posts included vaping, smoking, addiction, withdrawal, nicotine health risks, and quit nicotine, with mentions of going "cold turkey" and needing help in quitting. Cessation was a common topic, with mentions of quitting and stopping smoking. Social bots discussed unsubstantiated health claims including how hypnotherapy, acupuncture, magnets worn on the ears, and time spent in the sauna can help in smoking cessation.

CONCLUSIONS

Health education efforts are needed to correct unsubstantiated health claims on Twitter and ultimately direct individuals who want to quit smoking to evidence-based cessation strategies. Future interventions could be designed to follow these topics of discussions on Twitter and engage with members of the public about evidence-based cessation methods in near real time when people are contemplating cessation.

Gabapentin for cessation of smoking and non-smoking tobacco habits in Indian population

BACKGROUND

The effectiveness of gabapentin in tobacco dependence has been evaluated by many researchers. The randomized control trials, testing the efficacy of gabapentin in quitting the habit in smokers and users of smokeless tobacco, have not been published yet. We attempted to address this lacuna in knowledge in reducing dependence on tobacco use by gabapentin.

METHODS

Our study involves 150 study subjects, 75 of whom were identified as chronic users of tobacco and assigned randomly to one of the three groups consisting of 25 subjects each. Gabapentin in tablet form was prescribed thrice a day for 8 weeks wherein group 1 received a dose of 300mg, group 2 received 600 mg, and group 3 was prescribed 900 mg. An age and sex matched control group have received calcium tablets as placebo in three times daily dose for a period of 8 weeks.

RESULTS

Among the three doses of gabapentin, stoppage of habit was reported to be highest in the group-2 followed by group 1 and group 3 respectively. In our study, we found differences in response to quitting tobacco use between duration of habit prior to pharmacologic intervention amongst both smokers and the users of smokeless tobacco.

CONCLUSIONS

Gabapentin at dose of 600 mg TDS has optimum effect. Smokers having smoking for more than ten years showed notable benefit with gabapentin. Among smokeless tobacco users who quit tobacco dependence was better having history of habit less than 2 years.

Information and sin goods: Experimental evidence on cigarettes

We test the importance of information source on consumer choice in the context of sin goods, specifically electronic and tobacco cigarettes, among adult smokers. We proxy choice with intentions to vape and quit smoking in the next 30 days. We experimentally vary the information source: government, private companies, physicians, and no source. Our findings suggest that information source matters in the context of cigarettes choice for adult smokers. Private companies appear to be an important information source for cigarettes among adult smokers.

The Ethics of Tobacco Harm Reduction: An Analysis of E-Cigarette Availability From the Perspectives of Utilitarianism, Bioethics, and Public Health Ethics

Much evidence suggests e-cigarettes are substantially less harmful than combustible cigarettes. Assuming this is true, we analyze the ethical case for a policy of e-cigarette availability (ECA) as a tobacco harm reduction strategy. ECA involves making e-cigarettes available to allow smokers to switch to them, and informing smokers of the lower risks of e-cigarettes vis-à-vis smoking. After suggesting that utilitarian/consequentialist considerations do not provide an adequate ethical analysis, we analyze ECA using two other ethical frameworks. First, ECA is supported by a public health ethics framework. ECA is a population-level intervention consistent with respecting individual autonomy by using the least restrictive means to accomplish public health goals, and it supports equity and justice. Second, ECA is supported by four principles that form a biomedical ethics framework. By reducing smokers' health risks and not harming them, ECA fulfills principles of beneficence and non-maleficence. Because ECA allows smokers to make informed health decisions for themselves, it fulfills the principle requiring respect for persons and their autonomy. Here, we consider whether nicotine addiction and thus ECA undermine autonomy, and also discuss the ethical warrant for special protections for youth. Finally, ECA can also advance justice by providing a harm reduction alternative for disadvantaged groups that disproportionately bear the devastating consequences of smoking. Policies of differential taxation of cigarettes and e-cigarettes can facilitate adoption of less harmful alternatives by those economically disadvantaged. We conclude that public health and biomedical ethics frameworks are mutually reinforcing and supportive of ECA as a tobacco harm reduction strategy. Implications: Making e-cigarettes and information about them available is supported as ethical from multiple ethical perspectives.

Identifying factors that conjointly influence nicotine vaping product relative harm perception among smokers and recent ex-smokers: Findings from the 2016 ITC Four Country Smoking and Vaping Survey

BACKGROUND

Use of nicotine vaping products (NVPs) to replace smoking is often influenced by perceived harmfulness of these products relative to smoking. This study aimed to identify factors that conjointly influenced NVP relative harm perception among smokers and ex-smokers.

METHODS

Data (n = 11,838) from adult smokers and ex-smokers (quit < 2 years) who participated in the 2016 ITC 4 Country Smoking and Vaping Surveys in Australia, Canada, England and the US were analyzed. Decision tree models were used to classify respondents into those who perceived vaping as less harmful than smoking ("correct" perception) versus otherwise ("incorrect" perception) based on their socio-demographic, smoking and vaping related variables.

RESULTS

Decision tree analysis identified nicotine replacement therapy (NRT) harmfulness perceptions relative to smoking, perceived vaping portrayal in the media and other sources as positive, negative or balanced, recency of seeking online vaping information, and age as the key variables that interacted conjointly to classify respondents into those with "correct" versus "incorrect" harm perceptions of vaping relative to smoking (model performance accuracy = 0.70-0.74). In all countries, NRT relative harmfulness perception and vaping portrayal perception were consistently the two most important classifying variables, with other variables showing some country differences.

CONCLUSIONS

In all four countries, perception of NVP relative harmfulness among smokers and recent ex-smokers is strongly influenced by a combination of NRT relative harmfulness perception and vaping portrayal in the media and other sources. These conjoint factors can serve as useful markers for identifying subgroups more vulnerable to misperception about NVP relative harmfulness to benefit from corrective intervention.

E-Cigarette Promotion on Twitter in Australia: Content Analysis of Tweets

BACKGROUND

The sale of electronic cigarettes (e-cigarettes) containing nicotine is prohibited in all Australian states and territories; yet, the growing availability and convenience of the internet enable the promotion and exposure of e-cigarettes across countries. Social media's increasing pervasiveness has provided a powerful avenue to market products and influence social norms and risk behaviors. At present, there is no evidence of how e-cigarettes and vaping are promoted on social media in Australia.

OBJECTIVE

This study aimed to investigate how e-cigarettes are portrayed and promoted on Twitter through a content analysis of vaping-related tweets containing an image posted and retweeted by Australian users and how the portrayal and promotion have emerged and trended over time.

METHODS

In total, we analyzed 1303 tweets and accompanying images from 2012, 2014, 2016, and 2018 collected through the Tracking Infrastructure for Social Media Analysis (TrISMA), a contemporary technical and organizational infrastructure for the tracking of public communication by Australian users of social media, via a list of 15 popular e-cigarette-related terms.

RESULTS

Despite Australia's cautious approach toward e-cigarettes and the limited evidence supporting them as an efficacious smoking cessation aid, it is evident that there is a concerted effort by some Twitter users to promote these devices as a health-conducive (91/129, 70.5%), smoking cessation product (266/1303, 20.41%). Further, Twitter is being used in an attempt to circumvent Australian regulation and advocate for a more liberal approach to personal vaporizers (90/1303, 6.90%). A sizeable proportion of posts was dedicated to selling or promoting vape products (347/1303, 26.63%), and 19.95% (260/1303) were found to be business listings. These posts used methods to try and expand their clientele further than immediate followers by touting competitions and giveaways, with those wanting to enter having to perform a sequence of steps such as liking, tagging, and reposting, ultimately exposing the post among the user's network and to others not necessarily interested in vaping.

CONCLUSIONS

The borderless nature of social media presents a clear challenge for enforcing Article 13 of the World Health Organization Framework Convention on Tobacco Control, which requires all ratifying nations to implement a ban on tobacco advertising, promotion, and sponsorship. Countering the advertising and promotion of these products is a public health challenge that will require cross-border cooperation with other World Health Organization Framework Convention on Tobacco Control parties. Further research aimed at developing strategies to counter the advertising and promotion of e-cigarettes is therefore needed.

Perceived relative harm of heated tobacco products (IQOS), e-cigarettes, and cigarettes among adults in Canada: Findings from the ITC Project

INTRODUCTION

Tobacco companies have introduced heated tobacco products (HTPs), such as IQOS, which may compete with e-cigarettes among smokers interested in switching to potentially reduced-risk products. Non-smokers may also start using IQOS if they believe this product is less harmful than other nicotine products. Smokers’ and non-smokers’ decisions may be driven by relative harm perceptions of emerging nicotine products. We aimed to examine relative harm perceptions between IQOS, e-cigarettes, and cigarettes, among nicotine product users and non-users.

METHODS

We conducted a web survey with Canadian respondents (aged ≥20 years; n=268) in September–October 2018. Perceptions about relative harm between IQOS (available for sale since 2017 and subject to the same comprehensive marketing restrictions as cigarettes in Canada), e-cigarettes, and cigarettes, were assessed among non-users (n=79), exclusive smokers (n=78), exclusive e-cigarette users (n=32), and dual users (n=79). Multiple logistic regression explored the association between relative harm perceptions and nicotine-use status, adjusting for sociodemographic variables.

RESULTS

Over half of respondents perceived IQOS as equally or more harmful than e-cigarettes (53.7%), while almost a quarter either reported IQOS as less harmful than e-cigarettes or were uncertain (22.7% and 23.5%, respectively). Two-thirds of respondents (65.7%) perceived e-cigarettes as less harmful than cigarettes, yet only half (48.1%) perceived IQOS as less harmful than cigarettes. Both exclusive and dual e-cigarette users, but not exclusive smokers, had higher odds of perceiving IQOS as more harmful than e-cigarettes and less harmful than cigarettes compared to non-users.

CONCLUSIONS

Most nicotine users and non-users perceive differential health risk across IQOS, e-cigarettes, and cigarettes. Although e-cigarettes are generally viewed as less harmful than cigarettes, the perceived harm of IQOS was unclear.

Perception of the relative harm of electronic cigarettes compared to cigarettes amongst US adults from 2013 to 2016: analysis of the Population Assessment of Tobacco and Health (PATH) study data

BACKGROUND

Electronic cigarettes (e-cigarettes) have been characterised as significantly less harmful than cigarettes by many health agencies and regulators globally. In this study, we examined to what extent perceived relative harms of e-cigarettes compared to cigarettes have changed in the USA.

METHODS

We analysed the data from the longitudinal and nationally representative, Population Assessment of Tobacco and Health Study to assess the relative perceived harm of e-cigarettes amongst US adults between 2013 and 2016.

RESULTS

The proportion of US adults who correctly perceived e-cigarettes as less harmful than cigarettes decreased each year from 41.1% (CI 40.1-42.1%) in 2013-2014, 31.5% (CI 30.8-32.2%) in 2014-2015 and 25.3% (CI 24.6-26.0%) in 2015-2016. Concurrently, the proportion of US adults who perceived e-cigarettes as equally, or more, harmful than cigarettes increased from 53.7% (CI 52.3-55.1%), 64.9% (CI 63.6-66.2%) to 72.7% (CI 71.5-73.9%) respectively. The proportion of US adults who held negative relative harm perceptions of e-cigarettes increased regardless of current smoking or vaping status by 24.6% and 29.6% respectively within 3 years. In Wave 3, the proportion of current smokers who perceived the relative harm of e-cigarettes as less harmful was lower at 29.3% (CI 28.2-30.4%) compared to current e-cigarette users at 43.5% (CI 40.3-46.7%). Former smokers who used e-cigarettes and believed that they were equally, or more, harmful than cigarettes in 2014-2015 had significantly higher rates of smoking relapse in the following year, 29% and 37% (p < 2.2e-16), respectively, compared to those with positive relative harm perceptions who reported relapse rates of 19%.

CONCLUSIONS

In this study, the proportion of US adults who incorrectly perceived e-cigarettes as equal to, or more, harmful than cigarettes increased steadily regardless of smoking or vaping status. Current adult smokers appear to be poorly informed about the relative risks of e-cigarettes yet have potentially the most to gain from transitioning to these products. The findings of this study emphasise the urgent need to accurately communicate the reduced relative risk of e-cigarettes compared to continued cigarette smoking and clearly differentiate absolute and relative harms. Further research is required to elucidate why the relative harm of e-cigarettes is misunderstood and continues to deteriorate.

Beliefs about the Harmfulness of Heated Tobacco Products Compared with Combustible Cigarettes and Their Effectiveness for Smoking Cessation among Korean Adults

Heated tobacco products (HTPs) have been widely used in Korea since their introduction in 2017. In this study, we investigated the perceptions of their relative harmfulness and smoking cessation effects. We performed an online survey in 7000 Koreans in 2018 (2300 males and 4700 females aged 20-69 years) by matching their age, sex, and provincial distribution. To investigate the factors causing HTPs to be perceived as less harmful than combustible cigarettes (CCs) and helpful for smoking cessation, we used multivariable logistic regression analyses. HTPs were less harmful than CCs in 16.8% of participants, particularly among HTP-only users and dual and triple users of HTPs, electronic cigarettes (ECs), or CCs than among CC-only users, those who were aged ≤ 34 years, males, and those with higher incomes. HTPs were reportedly helpful for smoking cessation in 11.2% of participants. Similar perceptions were more likely among HTP-only users, as well as dual and triple users than among CC-only users and adults with higher education/incomes. Although Korean adults generally had negative perceptions of the harmfulness and smoking cessation effects of HTPs compared with CCs, dual and triple users were more likely to have positive perceptions. Monitoring the use of multiple tobacco products and HTPs is a new challenge for Korean policymakers.

Comparison of a General and Conditional Measure of E-Cigarette Harm Perceptions

Measures of tobacco product harm perceptions are important in research, given their association with tobacco use. Despite recommendations to use more specific harm and risk perception measures, limited research exists comparing different wordings. We present exploratory survey data comparing young adults' (ages 18-29) responses to a general e-cigarette harm perception measure ("How harmful, if at all, do you think vaping/using an e-cigarette is to a user's health?") with a more specific conditional measure, which personalized the behavior/harm ("imagine you vaped," "your health") and presented a specific use condition (exclusive daily vaping) and timeframe (10 years). Data were collected in January 2019 (n = 1006). Measures were highly correlated (r = 0.76, Cronbach's α = 0.86), and most (65%) provided consistent responses, although more participants rated e-cigarettes as very or extremely harmful using the conditional (51.6%) versus the general (43.9%) harm measure. However, significant differences in harm ratings were not observed among young adults who currently vaped. Correlations between each harm perception measure and measures of e-cigarette use intentions were similar. More specifically worded harm perception measures may result in somewhat higher e-cigarette harm ratings than general measures for some young adults. Additional research on best practices for measuring e-cigarette and other tobacco harm perceptions is warranted.

Perceived risk of electronic cigarettes compared with combustible cigarettes: direct versus indirect questioning

INTRODUCTION

Tobacco companies claim that a large proportion of the population perceives potential modified risk tobacco products as equally or more harmful than cigarettes, and argue misperceptions need to be corrected using modified risk claims. However, the studies they cite predominantly use one specific measurement of comparative risk. We analysed a representative sample of US adult smokers and non-smokers to examine whether the proportion who report e-cigarettes as less harmful than regular cigarettes differs depending on how the comparative risk questions were presented.

METHODS

We analysed data from the 2017 Tobacco Products and Risk Perceptions Survey. Comparative risk of cigarettes and e-cigarettes was measured in two ways: direct (single question) and indirect (by measuring perceived risk of both in separate questions and then subtracting the scores from each other).

RESULTS

When asked to compare harms of e-cigarettes and cigarettes directly (single question), 33.9% of participants identified e-cigarettes as less harmful than cigarettes, 36.4% reported equal harm, 4.3% said e-cigarettes were more harmful and 25.3% said 'I don't know'. When asked indirectly (separate questions), 42.1% identified e-cigarettes as less harmful than cigarettes, 23.8% said they were of equal harm, 7.1% perceived e-cigarettes to be more harmful and 27.1% did not know.

CONCLUSION

Our study offers evidence to suggest the need to use both direct and indirect risk questions when assessing the public's perceptions of harms associated with novel tobacco products.

Assessing comprehension and perceptions of modified-risk information for snus among adult current cigarette smokers, former tobacco users, and never tobacco users

INTRODUCTION

Snus, a low nitrosamine smokeless tobacco product, presents less risks to health than cigarettes. Effectively communicating such risk information could facilitate smokers switching completely to snus, thereby benefiting public health.

METHODS

This study assessed comprehension and perceptions of modified-risk information regarding snus. Adult cigarette smokers, former tobacco users, and never tobacco users (N = 3,922) from a US internet panel viewed an advertisement stating that smokers who switched completely to snus could greatly reduce risk of lung cancer, respiratory disease, heart disease, and oral cancer. Respondents answered questions regarding the modified-risk information and rated perceived risks of snus relative to cigarettes and other smokeless tobacco products.

RESULTS

Across the four diseases mentioned in the advertisement, most respondents (49.7%-68.6%, across tobacco user groups) understood that snus presents less risk than cigarettes but is not completely safe. Some indicated snus presents the same risk as cigarettes; this was highest for oral cancer (33.7%-42.02%) and lowest for lung cancer (15.4%-23.1%) and respiratory disease (15.6%-23.4%). Majorities understood snus is addictive (77.7%-87.9%), quitting all tobacco is the best option for smokers (83.6%-93.1%), and non-users of tobacco should not use snus (80.4%-87.8%). Only 2.1%-5.8% indicated smokers would receive a health benefit if they continued to smoke while using snus.

CONCLUSIONS

The modified-risk information, conveying that snus presents less risk than cigarettes but is not completely safe, was understood by majorities of respondents. Differential risk beliefs across diseases suggest responses were shaped not only by the modified-risk information, but also by intuitions and pre-existing beliefs about tobacco products.

News that Takes Your Breath Away: Risk Perceptions During an Outbreak of Vaping-related Lung Injuries

We study the impact of new information on people's perceptions of the risks of e-cigarettes. In September 2019 the U.S. experienced an outbreak of e-cigarette, or vaping, associated lung injuries (EVALI). The EVALI outbreak created an information shock, which was followed by additional new information in a later CDC recommendation. We use data on consumer risk perceptions from two sets of surveys conducted before (HINTS survey data) and during the EVALI outbreak (Google Survey data). The empirical model examines changes in risk perceptions during the early crisis period when the CDC was warning consumers that they should avoid all vaping products and during a later period when the message was refined and focused on a narrower set of illegal vaping products that contain THC (the main psychoactive compound in marijuana). Econometric results suggest that the immediate impact of the first information shock was to significantly increase the fraction of respondents who perceived e-cigarettes as more harmful than smoking. As the outbreak subsided and the CDC recommendation changed to emphasize the role of THC e-cigarette products, e-cigarette risk perceptions were only partially revised downwards. Individuals who had higher risk perceptions showed a weaker response to the first information shock but were more likely to later revise their risk perceptions downwards. We conclude the paper by discussing the public policy issues that stem from having risk perceptions of e-cigarette relative to combustible cigarettes remain at these elevated levels where a substantial portion of consumers believe that e-cigarettes are more harmful than cigarettes.