Current health warnings, such as those implemented by the TPD, may inadvertently deter smokers from initiating EC use and substituting their smoking for vaping due to their sole emphasis on the potential health-related harms of nicotine(6,32). This may be problematic to the extent that, for smokers, EC have been shown to be more efficacious than nicotine replacement therapies(13) as well as useful tools to prevent relapse(55). One way to encourage use of EC in smokers may be to refocus warning labels away from absolute potential harms to ones conveying risks relative to smoking. In this paper, we describe the development of a set of eight alternative health messages for EC packages and the testing of these messages against the current TPD warning messages on understandability, believability and convincingness. We also present differences between smokers, non-smokers and dual users.
From 26 original messages, we explored perceived understandability, believability and convincingness of the 8 relative risks messages most highly rated by experts and 2 current TPD messages. The two current TPD messages were consistently rated the highest for combined understandability, believability and convincingness rating, but did not differ significantly from four relative risk messages; “Completely switching to e-cigarettes lowers your risk of smoking related diseases” (RRM11), “Use of this product is much less harmful than smoking” (RRM5), “Completely switching to e-cigarettes is a healthier alternative to smoking” (RRM20), and “This product presents substantially lower risks to health than cigarettes” (RRM7). In terms of the distinct dimension ratings, all messages were rated highly on ‘understandable’. Importantly, we did not detect a difference between relative risk messages and the TPD messages in this domain; mean ratings were all above 5 indicating that they were as understandable as the current TPD standard. The messages that scored the highest on ‘believable’ and ‘convincing’ were RRM11 and RRM5 alongside the two TPD messages. Compared to dual users, non-smokers attributed higher scores to TPD1 (which emphasises nicotine addiction), whilst dual users rated RRM12, “This product is a safer alternative to smoking”, more favourably than non-smokers.
What may explain the observation that the TPD received the highest ratings compared to the relative risk messages overall? One possibility regarding believability may be due to pre-existing beliefs around the health risks and addictive properties of nicotine. There are many examples in the literature demonstrating public misperceptions of the harms of nicotine(32). In one online survey, smokers reported beliefs that very low nicotine cigarettes were less carcinogenic(56) whilst only 9% of a UK sample accurately recognised that the harms of smoking are not caused by nicotine(57). Our own recent work has shown TPD messages were associated with greater addictiveness and harm perceptions of EC especially in non-smokers/non-EC users(58). Hence, the nicotine addiction warning conveyed by the TPD may align with current tobacco and nicotine beliefs.
Another explanation for the higher endorsement of the TPD as the most believable and convincing could be due to previous exposure. It is plausible that through repeated exposure, this familiarity may enhance message credibility and acceptability(59). It is highly encouraging that despite the lack of familiarity with the relative risk messages, four messages did not statistically differ from the TPD messages. However, this also means that a familiarity explanation is not sufficient in isolation. Indeed, it could be argued that because novelty requires greater cognitive demand, new, unfamiliar content may increase attention to these messages. Regardless of preferred explanation, that these messages were rated as favourably as the TPD in a sizeable European sample, suggests that such relative risk messages have equal persuasive potential and good utility for future studies exploring how best to communicate the relative risks of EC on EC packs.
Importantly, our data did not indicate that these relative risk messages would lead to unintended consequences in non-smokers. Consistent with our previous findings(58) and those of others(31,60,61), non-smokers were more likely to endorse the TPD messages. More specifically, non-smokers ascribed greater believability and convincingness to the TPD1 compared to dual users, whilst dual users tended to rate the relative risk messages (i.e. “This product is a safer alternative to smoking”) more favourably in comparison to non-smokers and (i.e. “Use of this product is much less harmful than smoking”) compared to smokers. That non-smokers were less likely to endorse the relative risks messages compared to dual users suggests they may be less receptive to such messages. This is important insomuch that persuasive health messaging on EC packaging, needs to encourage smokers to switch to reduced risk products without enticing non-smokers. One possible explanation for the higher ratings of the relative risk messages in dual users compared to smokers may be that dual users are more likely to be better informed about EC relative risks due to their experience of using the product (62). Thus, ways of enhancing the credibility of relative risk messages certainly warrants further investigation. Because such relative risk messages (“Use of this product is much less harmful than smoking” RRM5) are more likely to increase use intentions in smokers than non-smokers (58), they hold promise for further empirical investigation.
Future research could evaluate the universality of these messages by testing them in different regulatory environments outside of the EU as well as in developing countries with high smoking prevalence. Future work could also evaluate these relative risk messages’ persuasiveness potential further by testing their legibility (fonts, colour, font size, positioning and prominence on the pack, background contrast, and so on), readability, memorability and perceptual fluency (how easily and favourably they can be processed and evaluated).
The method used here presents some potential limitations. Although a reasonable sample size was used, a little above 10% were based in the UK and the vast majority were from other European countries. It is, therefore, possible that the results were influenced by differential past exposure and familiarity with the TPD messages. It is worth noting that our analyses did not include exclusive EC users. Given dual users showed greater endorsement of the relative risk messages compared to smokers, these ratings could have been even higher had exclusive EC users been included. A further possible limitation is the over-representation of individuals from managerial and professional groups over those from routine and manual occupations given that smoking is largely concentrated in the latter as opposed to the former groups. Whilst useful, findings are confined to intentions and do not explore changes or fluctuations in perceptions or, how intentions translate into behaviours.