The effects of the European e-cigarette health warnings and comparative health messages on non-smokers' and smokers' risk perceptions and behavioural intentions

Examining Perceptions of Uncertain Language in Potential E-Cigarette Warning Labels: Results from 16 Focus Groups with Adult Tobacco Users and Youth

E-cigarette use among youth presents a public health risk. Yet, cigarette smokers who substantially reduce their smoking or switch completely from traditional combustible cigarettes could benefit. As science about e-cigarettes is continually emerging, any potential warnings are likely to contain uncertain language. Hedged verbiage may impact decision making. To assess reactions, we conducted 16 online focus groups; 8 with youth (n = 32, grouped by gender and by vaping experience) and 8 with adult tobacco users (n = 37, grouped by smokers, dual users of e-cigarettes and cigarettes, and former smokers who switched to e-cigarettes). Each focus group viewed and discussed 8 potential warnings messages. We conducted an inductive thematic analysis of the reactions to warning messages that contain uncertain language. Respondents' reactions were often negative, but varied based on specific usages of uncertainty, existing beliefs about uncertainty in law and science, and smoking/vaping use patterns that supported the use of uncertainty related to e-cigarettes. Many youth (and some adults) believed that uncertain language enabled audiences to minimize the likelihood of harm or interpreted it as meaning there are both healthy and unhealthy e-cigarettes. This qualitative study provides evidence that the use of types of uncertain language, the frequency of that use, and/or the selection of particular words in warnings, might not achieve the intended public health aims of increasing understanding of risk, deterring youth uptake, and/or facilitating a substantial switch from cigarettes. The use of certain types of uncertain language appears to have significant potential to bring unintended consequences. Suggestions for research and policy are included.

The Influence of E-cigarette Warning Labels on Youths' Use Intentions - A Mediation Analysis of Role of Perceived Harm

Background: Electronic cigarettes (e-cigarettes) were introduced to the United States marketplace in 2007 and had dominated all other tobacco products used by youth by 2014. In May 2016, the Food and Drug Administration extended the final rule to include e-cigarettes in implementing text-based health warnings on cigarette packs and advertising, as required by the 2009 Tobacco Control Act. This study tested the hypothesis that youth's perceived harm of using e-cigarettes mediates the impact of seeing warning labels on their use intentions. Methods: We used a cross-sectional quantitative research design to analyze the 2019 National Youth Tobacco Survey data from 12,563 students in middle schools (grades 6 - 8) and high schools (grades 9 - 12) in the U.S. We conducted the 4-step Baron and Kenny Mediation Analysis using IBM SPSS® Hayes' PROCESS macro analysis. Results: Our study revealed a mediational process's presence, confirming the mediational role of youth's perceived harm of e-cigarettes on the relationship between seeing a warning label and their use intentions. Conclusion: This study provided insights into the relationship between seeing warning labels and the intention to use e-cigarettes among youth. Through the Tobacco Control Act, influential warning labels potentially increase youth's perception of harm in e-cigarettes, lowering their intention to use.

E-Cigarettes and Cardiopulmonary Health: Review for Clinicians

Electronic cigarettes (e-cigarettes) are battery powered electronic nicotine delivery systems that use a propylene glycol/vegetable glycerin base to deliver vaporized nicotine and flavorings to the body. E-cigarettes became commercially available without evidence regarding their risks, long-term safety, or utility in smoking cessation. Recent clinical trials suggest that e-cigarette use with counseling may be effective in reducing cigarette use but not nicotine dependence. However, meta-analyses of observational studies demonstrate that e-cigarette use is not associated with smoking cessation. Cardiovascular studies reported sympathetic activation, vascular stiffening, and endothelial dysfunction, which are associated with adverse cardiovascular events. The majority of pulmonary clinical trials in e-cigarette users included standard spirometry as the primary outcome measure, reporting no change in lung function. However, studies reported increased biomarkers of pulmonary disease in e-cigarette users. These studies were conducted in adults, but >30% of high school-age adolescents reported e-cigarette use. The effects of e-cigarette use on cardiopulmonary endpoints in adolescents and young adults remain unstudied. Because of adverse clinical findings and associations between e-cigarette use and increased incidence of respiratory diseases in people who have never smoked, large longitudinal studies are needed to understand the risk profile of e-cigarettes. Consistent with the Centers for Disease Control and Prevention recommendations, clinicians should monitor the health risks of e-cigarette use, discourage nonsmokers and adolescents from using e-cigarettes, and discourage smokers from engaging in dual use without cigarette reduction or cessation.

'I perceive it to be less harmful, I have no idea if it is or not:' a qualitative exploration of the harm perceptions of IQOS among adult users

BACKGROUND

Harm perceptions of tobacco and nicotine products can influence their use and could be targeted by policies to change behaviour. IQOS was introduced to the UK in 2016, and there is little independent qualitative research on IQOS harm perceptions. This study explored the perceived health harms of IQOS to users and those exposed to the emissions, what shapes these perceptions, and what participants wanted to know about the harms of IQOS.

METHODS

Qualitative interviews in London, UK, with 30 adult current and former IQOS users who currently smoked or quit smoking in the last 2 years.

RESULTS

IQOS was perceived as less harmful than smoking but not risk-free, although there was great uncertainty. Influences on harm perceptions were consolidated into six themes: (1) dominance of manufacturer claims influenced perceptions that IQOS is less harmful than smoking to users and those around them, although mistrust of the tobacco industry heightened scepticism about harms; (2) limited independent and long-term research led to uncertainty about harms, although some participants trusted IQOS would not be marketed if it were very harmful. Participants wanted more independent and long-term studies into harm; (3) appearance of HEETS (tobacco sticks) packaging conveyed reduced harm because packets were 'pretty', without graphic/specific warnings, although written warnings conveyed some harm. Participants wanted more information on HEETS packets about harms; (4) process of heating and HEETS contents-heating, compared with burning, tobacco was perceived to produce fewer harmful chemicals, while tobacco, nicotine, and chemicals in HEETS were perceived to cause some harm. Participants wanted clarification about the harms of heating tobacco and HEETS ingredients; (5) improvements in physical health and personal appearance reduced perceptions of harm; (6) differences in sensory experiences (taste, sight, smell) when using IQOS over smoking reduced perceptions of harm, while 'black' deposits inside IQOS led to perceptions of some harm. Reduced volume and smell of IQOS emissions also reduced perceptions of harm to non-users exposed to the emissions.

CONCLUSIONS

IQOS was perceived as less harmful than smoking but not risk-free, although there was great uncertainty. Participants wanted clarification about IQOS harms from independent sources in accessible forms, specifically related to HEETS ingredients, heating tobacco, and emissions to others.

Analysis of on-pack messages for e-liquids: a discrete choice study

BACKGROUND

Policymakers wishing to encourage smokers unable to quit to switch to using electronic nicotine delivery systems (ENDS) also need to consider how to deter ENDS use among non-smokers. We examined whether reduced-risk messages could increase ENDS' appeal among smokers and if increased-risk messages could decrease appeal among susceptible non-smokers, occasional and former smokers.

METHODOLOGY

An online discrete choice experiment tested three attributes: information message, nicotine content (0 mg or 3 mg) and flavour (tobacco, menthol or fruit). The sample comprised 352 current smokers, 118 occasional and former smokers, and 216 ENDS-susceptible never smokers. Smokers viewed reduced-risk messages that encouraged switching to ENDS, while other groups viewed increased-risk messages that discouraged ENDS use. All groups saw a typical addiction warning. We analysed the data by estimating multinomial logit regression and adjusted latent class analysis models.

RESULTS

Relative to no message, reduced risk-messages increased the appeal of ENDS uptake among one class of smokers (33.5%) but decreased appeal among other smokers. However, among all smokers, reduced-risk messages increased preference more than a dissuasive addiction warning. By contrast, among occasional or former smokers, and susceptible non-smokers, all information messages discouraging ENDS use, including an addiction warning, decreased preference relative to no message.

CONCLUSIONS

On-pack relative-risk messages about ENDS could make transition more attractive to smokers while increased-risk messages could deter ENDS uptake among susceptible non-smokers, occasional and former smokers. Communicating diverse messages via discrete channels could recognise heterogeneity among and between smokers and non-smokers.

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.

Communicating the relative health risks of E-cigarettes: An online experimental study exploring the effects of a comparative health message versus the EU nicotine addiction warnings on smokers' and non-smokers' risk perceptions and behavioural intentions

INTRODUCTION

This study investigated the effects of the European Union Tobacco Products Directive [EU-TPD] Article 20 E-cigarette (EC) health warnings ("This product contains nicotine which is a highly addictive substance. [It is not recommended for non-smokers.]") and a comparative harm message ("Use of this product is much less harmful than smoking" [COMP]) on smokers' and non-smokers' perceptions and behavioural intentions.

METHODS

2495 UK residents (1283 smokers and 1212 non-smokers) self-reported perceived harm, addictiveness, EC effectiveness, social acceptability, and intentions to purchase and use EC, and in smokers, intentions to quit and intentions to use EC in future quit attempts. These were measured before and after exposure to EC images containing either the TPD, COMP, TPD + COMP or no message.

RESULTS

Non-smokers had higher harm, addictiveness and lower social acceptability perceptions. TPD presence increased, whilst COMP decreased, harm and addictiveness perceptions in both groups. For smokers only, harm perceptions were lower following exposure to COMP alone vs. no message. For non-smokers the TPD increased harm perceptions vs. no message. There were no effects on social acceptability, EC effectiveness or use intentions. In smokers only, purchase and quit intentions were higher following exposure to the COMP alone.

CONCLUSION

TPD messages may be effective smoking prevention tools, although the COMP message was more effective in reducing harm perceptions and increasing use intentions in smokers. That COMP did not increase use intentions in non-smokers suggest that such exposures may potentially act as an effective harm reduction tool without resulting in increased uptake among non-smokers.