Why Do Some Adults Who are Smoking Perceive E-cigarettes to be More Harmful than Combustible Cigarettes?

doi:10.21203/rs.3.rs-3231318/v2

Download PDF

Research Article

Why Do Some Adults Who are Smoking Perceive E-cigarettes to be More Harmful than Combustible Cigarettes?

https://doi.org/10.21203/rs.3.rs-3231318/v2

This work is licensed under a CC BY 4.0 License

Version 2

posted

You are reading this latest preprint version

Whilst e-cigarettes have been characterised by respected public health bodies as being substantially less harmful than combustible tobacco products, nevertheless research has shown that a significant minority of adults, including those who are smoking, perceive e-cigarettes to be as harmful or more harmful than combustible cigarettes. In this paper we draw upon qualitative data from interviews with U.K. adults who are smoking to look at the reasons why e-cigarettes may be viewed as more harmful than combustible cigarettes. The belief that e-cigarettes may be more harmful than combustible cigarettes was based on a complex array of knowledge, belief, reasons, fears, predictions, reactions, and judgements covering such topics as the technological i.e. non-natural nature of e-cigarettes, uncertainties as to the content of e-liquids, perceptions that these devices expose the user to greater harm resulting from their being used with greater frequency than combustible tobacco products, fear around long-term harm of e-cigarettes, scare stories in the media and concerns around addiction. There is an important need for clear communication from responsible public health bodies and the media conveying the important information to those adults who are continuing to smoke that e-cigarettes are substantially less harmful than combustible tobacco products, and that those adults who are unable or unwilling to quit smoking using validated means of smoking cessation should consider switching to e-cigarettes or other non-combustible tobacco products as a way of reducing the harms they are being exposed to as a result of continuing to smoke.

According to the Global Disease Study there were an estimated 7.69m deaths attributable to smoking in 2019 (He et al 2022). Epidemiological studies have shown that amongst those adults who are smoking approximately one in two are likely to die as a result of their cigarette consumption, making combustible cigarettes one of the most, if not the most, harmful products available for retail sale across the globe (WHO 2008, Lam 2008). In stark contrast to the level of harm associated with the use of combustible cigarettes, e-cigarettes have been characterised by a range of respected public health bodies including; the U.K. Office for Health Improvement and Disparities, the U.K. Royal College of Physicians, the Royal College of General Practitioners, and Cancer Research U.K. (Public Health England 2015, U.K. Gov 2022) as substantially less harmful than combustible cigarettes.

Whilst some commentators have questioned the degree by which e-cigarettes may be less harmful than combustible cigarettes there are no credible commentators nor evidence suggesting that these devices may be more harmful than combustible cigarettes (McKee Capewell 2015). As well as exposing the user to lower levels of harm e-cigarettes have also been shown to assist individuals’ attempts at quitting smoking; with data showing that the use of e-cigarettes is associated with an increased number of quit attempts, and an increased likelihood that those quit attempts will have been successful (Mok et al 2022). Where e-cigarettes have been compared to other validated means of smoking cessation, these devices have been shown to be at least as effective, and in some cases more effective, than those other methods (Hayek et al 2019). Further, research has shown that these devices are popular amongst those adults who are smoking and those who are seeking to quit (ASH2021). Within the United States, the Food and Drug Administration has recently provided marketing authorisations to a small number of e-cigarette manufacturers on the basis that their specific devices have been judged to be “appropriate for the protection of the public health (FDA2021). Within the U.K., e-cigarettes have been identified by the U.K. government as having the potential to assist adults in quitting smoking, with the government recently announcing a scheme whereby adults who are smoking can be exchange their combustible cigarettes for e-cigarettes at no charge (Dept of Health and Social Care 2023).

Despite such positive assessments a wide range of research has shown that a significant proportion of adults who are smoking perceive e-cigarettes to be more harmful than combustible tobacco products (Malt et al 2020, Manderski et al 2021, Moysidou et al 2016). Malt and colleagues analysed data from three waves of the longitudinal “Population Assessment of Tobacco and Health” study undertaken within the U.S. Over the first two waves of the PATH study the proportion of U.S. adults who perceived e-cigarettes to be more harmful than combustible tobacco products increased from 6.5% to 9.6% whilst in wave three the proportion had increased further to 9.8% (Malt et al 2020). Bandi and colleagues (2022) reported that the proportion of U.S. adults who perceive e-cigarettes to be more harmful than combustible cigarettes increased from 12.8% in 2019 to 28.3% between 2019 and 2020. The perception of e-cigarettes as being more harmful, or equivalently harmful, as combustible tobacco products is by no means confined to adult who are smoking smokers or to the general population. In a survey of 2,058 U.S. physicians, for example, Delnevo and colleagues found that 60% of those questioned perceived all tobacco products as having the same level of harm (Delnevo et al 2022).

Within the U.K., both general population surveys, and surveys of adults who are smoking, have similarly identified a significant proportion of adults perceiving e-cigarettes as being at least as harmful as combustible tobacco products (U.K. Gov 2022). In a survey conducted annually for the anti-smoking charity “Action on Smoking and Health”, 32% of adults who were smoking in 2021 perceived e-cigarettes to be as harmful or more harmful than combustible cigarettes, whilst amongst adults in general, 33% perceived e-cigarettes to be a lot more harmful, more harmful, or as harmful as combustible cigarettes (ASH 2021). Recent research has shown that where e-cigarettes are perceived as being more harmful than combustible cigarettes, there is a reduced likelihood that these devices will be used as an aid to quitting by those who are smoking (Brose et al 2015, Fong et al 2022).

In this paper we report the results of qualitative research designed to explore the reasons that may lie behind the judgement, on the part of at least some adults who are smoking, that e-cigarettes are more harmful than combustible tobacco products.

In June 2022 we undertook a cross-sectional web-based survey combining both quantitative and qualitative data collection methods. Participants were 100 U.K. adults aged 21 to 60 years, who were currently smoking combustible cigarettes and who were no non-current users of any alternative nicotine product, including e-cigarettes, other electronic vaping products, Heated Tobacco Products (HTP), or Nicotine Replacement Therapy (NRT). Participants were excluded from the research if they had any present, or previous diagnosed history of psychiatric disorder, if they had no access to a reliable internet facility, if they were not fluent in English (necessary for the online interview that formed a key part of the research, and if they had current or recent past contact with the sponsoring agency or any company selling tobacco- or nicotine-based products.

Study participants were recruited from the Schlesinger Group Panel (www.SchlesingerGroup.com). Panel members who indicated an interest in hearing about the research were directed to a web page displaying the online study Informed Consent Form (ICF). Individuals were asked to carefully read the on-screen ICF before deciding whether they wished to participate in this study. Those individuals who wanted to be considered for possible inclusion in the research were directed to a webpage outlining the consenting process for this study. Individuals who met the study inclusion criteria, and who indicated an interest in participating within the research, were directed to a webpage where they were asked to complete a short, standardized questionnaire designed to elicit their assessment of the absolute and relative harm of diverse nicotine delivery devices and substances. Following their completion of a standardized instrument study participants were asked to asked to identify a convenient time at which they would be willing to take part in a semi-structured interview during which they would be asked more detailed information about their views of diverse different nicotine products and other substances. Interviews lasted around 40 minutes and were undertaken, and audio recorded, via Zoom at a time that was convenient for individual interviewees.

In the quantitative research instrument used in this study, respondents were asked to indicate whether in their view e-cigarettes, or other electronic nicotine products, was less harmful, about the same, or more harmful than combustible cigarettes. In the semi-structured interviews respondents were invited to talk at greater length about their views of the relative harms of these products including setting out the reasoning behind their judgements as to how harmful e-cigarettes are compared to conventional combustible cigarettes.

Following notice of the research to Schlessinger panellists, a total of 617 individuals expressed an interest in the research - 495 of the 617 individuals who responded to the advert failed to meet the inclusion criteria. Out of the 122 eligible individuals, four chose not to schedule an interview session, five did not complete the harm perception questionnaire, and ten did not attend the qualitative interview session once arranged. A total of 103 interviews were conducted, with three interviewees subsequently excluded on the basis of inconsistencies in reports of their current smoking status.

In table 1 below we summarise the demographics and tobacco/nicotine product use behaviour of the study sample:

Table One Here

Amongst the 100 adults surveyed (all of whom were currently smoking) 59% perceived combustible cigarettes to be more harmful than e-cigarettes, 21% thought that e-cigarettes had the same level of harm as combustible cigarettes and 9% indicated that, in their view, e-cigarettes were more harmful than combustible cigarettes. 11% of respondents were unsure of the relative harm of combustible cigarettes and e-cigarettes. In the remainder of this paper, we look in detail at those smokers who indicated that in their view e-cigarettes were more harmful than combustible cigarettes with the focus of our interest being on how and why these smokers had come to perceive e-cigarettes to be so harmful despite the wide ranging evidence to the contrary.

Qualitative Data and Analysis

Across those adults who perceived e-cigarettes to be more harmful than combustible cigarettes there were a range of reasons offered in support of that view.

Scare Stories in the Media

In explaining their view of the harms of e-cigarettes, a small number of interviewees drew attention to what they regarded as alarming reports about e-cigarettes in the media:

There was this big scare about all these teenagers having this, their lungs filling with fluid from vaping and all, I can’t remember. You know I think it was very much, no one really knew if it was the cause or correlation or whatever was going on with it but I just thought like you’ve got, people don’t know and that was the problem is that they were, some people were saying yes it is the vape, some people were saying no it’s nothing to do with the vapes and I think the fact that there was no definitive answer is what makes me kind of uneasy with it. I think there’s just you know you just don’t know what you’re putting in your body.

I think it was probably that big news cycle scare we had a few years ago. Like I said who knows if that was, you know just scaremongering, or any actual evidence. I haven’t done my research. I’m talking about all these harms, but I actually have no idea really but also I think just kind of being irritated by people almost invading my space with it is probably what’s influenced my, you know my opinions of harm because it’s like I didn’t consent to this, I don’t want you near me with that so.

Despite some of the interviewees drawing attention to media coverage as being the reason why they perceived e-cigarettes to be more harmful than combustible cigarettes, in fact such media coverage was only one of the number of factors that appeared to lie behind individuals’ assessments of relative harm.

Concerns About Technology

In explaining their perception that e-cigarettes were likely to be more harmful than combustible cigarettes it was more common for interviewees to draw attention to what they felt were concerns around the -cigarettes technology itself; specifically that e-cigarettes were likely to be more harmful than combustible cigarettes because of the technological nature of the devices in contrast to what was seen as the “natural” quality of combustible cigarettes:

I think maybe because… I’m throwing off a bit about the electrical part… the electronic devices because anything that come- I think our body naturally has like some sort of electronic field within where how everything operates. And I just, I don’t know, I think maybe it’s a mental thing for me thinking that maybe if it’s something I’m electronically pulling something, like is it being charged as I’m inhaling it with the vape or something. Am I also pulling in other things into my body? Whereas at least with a cigarette you know, it’s, okay it’s bad enough because you’ve got the nicotine and the paper, the rolling paper that it’s in. But with the electrical device it’s like, okay, is there anything else that I’m inhaling? So, I think that’s more- So I think, yes, I think that’s probably why I don’t know. I think that’s what throws me off a little bit, yes.

E-cigarette is basically chemical, hydrocarbons you know, you've got hydrocarbons, you’ve got all different chemicals that are in the e-cigarette. So, if you’re smoking something organic, which is like tobacco is organic, it’s natural and smoking you know, chemicals like benzene and ethylene and so many chemicals. Obviously, chemicals are more harmful to your body than natural, organic stuff kind of thing. So, each of those chemicals, it's not natural, you know, it's like if you eat natural fruits and salad it’s good for you because it’s natural. But if you’re smoking e-cigarettes, it’s completely toxic, it’s chemically. It's like a chemical poisoning, basically.

The only thing is that I would think with an e-cigarette you’re inhaling something that is somewhat electrical, naturally I would think is that even a good thing? You know, so I think it, I think it would probably be a bit more dangerous, but I don’t know. But I think, yes, yes.

Frequency of Use

Along with concerns to do with the nature of the technology itself. concerns were raised as to the greater quantity of harm being caused by e-cigarettes deriving from the greater frequency with which these devices would be used compared to combustible tobacco products:

I don’t think, well my friends actually vape, and they used to smoke and I think that since they’ve been vaping if I’m in the car with them it’s in their hand. It’s constant whereas when they smoked it wasn’t constant because you couldn’t light up that cigarette every five minutes that you wanted to whereas you’ve got this vape, you just pick it up and that’s it, you keep putting it down. I think that’s had a big influence on my opinion on it but other than that I haven’t really read up on it to be honest because I don’t, I don’t know what’s right and what’s wrong on the Internet, but I have my own views on it. I just feel that it’s harmful. I think it’s the same as cigarettes. They tried to make it a substitute for smoking. It’s all the same, you’re putting the same stuff into your body.

I think the harm you’re going to do yourself; you’re going to put stuff in your body that you shouldn’t either way. I think with the smoking you have the restriction of you can’t smoke in cars, you shouldn’t smoke in cars, things like that and you kind of feel, I’m the kind of person I can’t sit in smoke. Yes, I smoke, I don’t like the smell of it. I smoke outside. With the vaping they don’t smell so I think that you’ve got that constantly there, it’s not causing an issue to you or anybody else because it doesn’t smell. Obviously if I’m in a car with somebody I’m taking that in as well so it’s no good for me. I don’t know I just think that it’s the same as smoking the vaping. I don’t see any difference. If not, it could be worse because they’ve manufactured a liquid that goes into this electronic device with stuff in that you don’t know what’s in there and you don’t know what’s in cigarettes either so it’s

I think, I think the vaping and the e-cigarettes are, I think it’s easier to do. Obviously if you’re at home say if you obviously didn’t have kids around you could smoke in your own living room if you were vaping. I mean personally I don’t smoke indoors. Obviously, I’ve got a child, I go outside but I find that people that vape they sit there with it constantly in their hands so they’re smoking more. They don’t have that break where they’re going outside for their cigarette break and it’s just there in front of them so they can do it inside. So, I think they’re doing it a lot more. It’s going to do more damage to their body in the long run because they’re vaping and smoking a lot more during the day.

In these cases it was the perceived greater frequency with which e-cigarettes were likely to be used (in contrast to the wide ranging restrictions around the use of combustible cigarettes) that resulted in e-cigarettes being judged to cause more harm than combustible cigarettes. The comparison of relative harm between combustible cigarettes and e-cigarettes was being influenced in some cases by a judgement about the relative frequency with which these products might be used rather than by a direct product to product comparison.

Uncertainty Regarding the Impact of Long-Term Use

In explaining their thinking as to why e-cigarettes were believed to be more harmful than combustible cigarettes, a number of interviewees drew attention to the uncertainty over the harms associated with the long-term use of these devices, with some interviewees drawing attention to how long it had taken for public health bodies to identify the health harms of combustible cigarettes:

I think it, the harm (of vaping) would be that dependency and you know the harm of not, I think the harm is not knowing what the harm is long-term. You know if you, if you’re vaping for 10/15 years what is that actually doing to your lungs, to your brain? You know you are, there are chemicals in a vape. People presume it’s just, oh it’s just water vapor and like bubble gum flavouring. It’s not, they have all sorts in there, we just don’t know what they are. Same with cigarettes you know for years everyone smoked you know because no one understood the harm of it and then decades later it’s causing cancer, it’s causing you know all sorts, people’s teeth and nails are falling out and I think that, that kind of goes the same with vapes. I think there’s just no one knows really what happens. It could be ruining your lungs; you just don’t know.

There you go. I know I’m inhaling nicotine, and everything bad for me. You don’t know actually know what you’re inhaling. In another 50 years, I think it will come out that they are awful for you. That’s my opinion. Maybe I’m wrong but nobody really tells you what’s in it. And that’s what scares me. You pick up these little- they’ve got like, little tubs, little bottles that you fill them up with. If you read the packet- which my lads have got them. It doesn’t say what it is. It will give you a rough description, but it doesn’t say what percentage of what is in these tubs. You’re going to look next time you buy one.

Uncertainty About E-liquid Content

In addition to expressing concerns about the technology of e-cigarettes some interviewees drew attention to their concerns around the chemicals contained within e-liquids:

I think the trouble is, even now, we’re still- nobody knows what’s really in it to cause massive effects. Smoking, we know what it’s going to do. We still smoke and we know exactly what it’s doing to us. E-cigarettes, we don’t know, but we still use them.

Because whatever it is in e-cigarettes is artificial, and man-made. Nicotine is natural. With these e-cigarettes, whatever it is you're smoking is man-made. It’s not been around long enough to cause- for instance, if you went and bought a vape machine, or whatever it is, it does not say on the packet anywhere it’s better for you than smoking. It doesn’t say it. They can’t say it because they don’t know if it’s true yet.

I think, I don’t know the heated devices I think that, I just think that an electronic device is, obviously smoking isn’t good either way, but I think the electronic devices are obviously doing something to the liquid or however it’s, whatever they’re using there. So, then you inhale it into your body and I think that the chemicals that are burning together when it’s being smoked I just think that it’s not doing any good for your lungs, your mouth and definitely you know it affects your breathing.

E-cigarette Use Much Less Bounded

Alongside concerns around the content of e-liquids and the frequency of their use, concerns were also expressed that the use of these devices was much less bounded than was the case with combustible cigarettes resulting in these devices being used much more widely than was the case with combustible tobacco products -thereby potentially exposing many more people to some level of harm:

My sister has a vape and it drives me mad, and she was, we were at a family dinner and she’s sitting there at the table inside vaping. I just thought no, this is gross. Like I didn’t ask, I don’t want to smell like peppermint oil whatever it is. It was, oh they just, it really drives me mad, and I think there’s just at least with like smoking you can you know there’s a smoking area, you don’t have to go in it. You know people can’t smoke inside anymore; people tend to like you can avoid it. With vaping people just seem to do it like they have no, I mean this is you’re really see this is really getting on my nerves just talking about it, people really just seem to be quite, they don’t care what you think of it. Like they don’t, because they think it’s harmless, I think that’s what annoys me. People think it’s harmless and they don’t actually know what they’ve, like my sister started vaping occasionally with her friends I would say maybe four months ago and now she’s constantly doing it. She’s got a full-on nicotine addiction, she never had any issue with smoking or anything like that and now she’s dependent on them I would say. She uses them when she’s in the car. I just think like this ugh. Her room smells of it as well and I just think it infuriates me that people presume they’re harmless and think that everyone else then wants to like sit in a cloud of water vaper or whatever. It’s, that’s what bothers me. I think it’s the social aspect more.

A small number of interviewees explained their perception of the greater harm associated with the use of e-cigarettes, in comparison to combustible cigarettes, by drawing attention to the nicotine content of e-liquids:

When you have like a substance like nicotine it alters your, your like neurotransmitters and you know the messages in your brain and how it receives them which is why you end up craving nicotine and things like that because your body builds up a certain tolerance and dependency and you see it with you get it with drugs like you know cocaine and all sorts, you see it with cigarettes, you see it with really kind of anything that alters that kind of neurochemistry and I think nicotine it’s, it almost scares me to have a dependency on something like that, like a real need for it and I’ve never been a full-time smoker or anything like that and I always remember like being very much like I’ll one cigarette or like one evening where I’ll be smoking and I’m not buying a pack because it’s just that dependency on something it intimidates me.

Finally, it was evident that for a small number of interviewees the perception that other people had that e-cigarettes were less harmful than combustible cigarettes generated a concern on their part that these devices might actually be causing more harm than combustible tobacco products:

I think they are more harmful now than I would have a few years ago and I think that’s because people presume they’re harmless. That’s what makes me feel they’re more harmful because people just think there’s no problem with it. It was the same with smoking like 50 years ago. People didn’t think anything of it. They would smoke with their kids in the same place and you just you presume it’s harmless and that creates a bigger problem so that’s kind of similarly how I feel…. I think that when you, you go into any situation and you think like oh like this is perfectly fine this, there are no risks here that is when you know you are more likely to have an issue. Like if you think like if you’re going to a sports day and you’re like oh I’m going to just go running you know I don’t need to do a stretch I can just run 200 metres and then that’s when you’re more like to harm yourself because you’re not anticipating that you might pull a muscle, you haven’t done any stetches. You have no idea as to like the dangers and I think everyone like vaping is so common now and just so accepted and I think the fact that no one’s thinking well actually I’m putting nicotine into my body, no one’s thinking oh you know this could be a problem. They just think oh it’s water vapour, it’s not smoke so it’s fine. It’s like that’s not true, it’s still chemicals and you know I’ve no idea how it works. I’ve no idea what’s in them. I think that’s the problem. That’s what makes you know something being harmless more harmful because you’re not prepared for any of it.

Drawing upon the qualitative interviews undertaken in this study it is clear that where adults who smoke perceive e-cigarettes to be more harmful than combustible cigarettes those judgements are based upon a complex amalgam of reasons, beliefs, fears, predictions, reactions, and judgements. Understanding the nature of those views, and what they are based upon, is important because of the strong likelihood that the perception that e-cigarettes are more harmful than combustible cigarettes is very likely to reduce the prospect of adults who are smoking using these devices as a means of quitting. Plainly this would be less of a problem if those adults were inclined to use other validated means of smoking cessation as their chosen means of quitting smoking. However, it is highly likely that a proportion of those adults who are unwilling or unable to quit smoking using other validated means of smoking cessation are continuing to smoke as a result of a perception that e-cigarettes are actually more harmful than the combustible tobacco products they are currently using (Yong et al 2022).

In the light of the findings presented here there is a clear need to ensure that adults who are smoking have access to the emerging evidence on the relative harm of combustible and non-combustion based nicotine products. However, at the present time there is a disconnect between the evidence on the relative harm of these products and the commitment to ensuring adults who are smoking have access to up to date information on the research showing that e-cigarettes are likely to be substantially less harmful than combustible tobacco products. Within the United States, for example, the Food and Drug Administration overseeing the Pre-Market Tobacco Application process has provided marketing authorizations to a small number of e-cigarette manufacturers on the basis that their products have been judged to be ‘appropriate for the protection of the public health’. Whilst there remains considerable uncertainty as to how the Food and Drug Administration has judged which e-cigarette products are indeed “appropriate for the protection of the public health”, and which can be sold within the United States on that basis, it is inconceivable that any new tobacco product could be judged as being ‘appropriate for the protection of the public health’ where it was seen to be more harmful than combustible tobacco products. However, whilst authorizing a small number of e-cigarettes for retail sale within the U.S. the Food and Drug Administration has shown little commitment to informing adults who are smoking of the decisions they have arrived at by which the authorized products are deemed to be less harmful than combustible cigarettes. Rather what occurs in practice is that it is the e-cigarette manufacturers who are informed as to whether their products have been authorized for retail sale within the United States though without that judgement itself being conveyed to manufacturers as something that can or should be conveyed thereafter to potential consumers of the authorized products. On that basis then the judgement attached to at least some e-cigarette devices that they can be sold within the U.S. on the basis that they are appropriate for the protection of the public health is conveyed rather more as a private communication for manufacturers rather than an opportunity for wider public health education to the population at large.

There is of course an important distinction here between societal or public health harm and the harm that may be caused to the individual should they choose to use either combustible or non-combustible tobacco products. On that basis it is easy to see why the FDA and other public health bodies may be unsure as to how widely they convey to adults who are smoking that there are some e-cigarette products that have been authorized for retail sale on the basis that those products are less harmful than combustible tobacco products. The danger here being that such communication may result in some adults who are smoking switching the using e-cigarettes who might otherwise have chosen to use a validate means of smoking cessation to wholly quit smoking and further that some adults who are not smoking on the basis of the serious health harms associated with smoking may choose to being to use e-cigarettes in the belief that these products are less harmful than combustible tobacco products. Similarly public health bodies may be further concerned that any positive communication of the evidence around the relative harm of combustible and non-combustible tobacco products might result in a greater proportion of young people initiating e-cigarette use in the belief that these products are indeed less harmful than combustible tobacco products. Concerns around the impact of respected public health bodies regulators or government spokespeople conveying the data on the relative harm of combustible and non-combustible tobacco products are clearly complex and by no means easily resolved. However, the failure to adequately convey the levels of relative harm between these products, even where those harms have been assessed, is very probably contributing to the mistaken perception on the part of at least some adults who are smoking that e-cigarettes are more harmful than combustible tobacco products and further reducing the likelihood of those alternative products being used as a means of quitting smoking.

The hesitancy on the part of public health bodies to better inform adults who are smoking about what is known about the relative harms of combustible and non-combustible tobacco products is by no means limited to the United States. Within the U.K. whilst a number of respected public health bodies and anti-smoking charities have expressed the view that e-cigarettes are significantly less harmful than combustible tobacco products still there has been no national health education, multi-media campaign, designed to inform adults who are smoking about the relative harms of combustible and non-combustible tobacco products. Rather the assumption seems to be that those adults who are smoking will acquire an understanding of the relative harms of these products which will inform their choice as to whether or not to use those products without there being a need for a national educational campaign presenting the evidence as to what is known currently about the relative harm between combustible and non-combustible tobacco products.

Finally, the evident reluctance on the part of public health bodies, and national governments, to commit to informing adults who are smoking about the evidence on relative harm is perhaps nowhere more clearly expressed than in the case of the World Health Organization which, in its own website, both poses the question of whether e-cigarettes are indeed less dangerous than combustible cigarettes, and then comprehensively fails to provide an answer to the question posed:

Question: Are e-cigarettes more or less dangerous than conventional tobacco cigarettes?

Answer: Both tobacco products and ENDS pose risks to health. The safest approach is not to use either.

The levels of risk associated with using ENDS or tobacco products are likely to depend on a range of factors, some relating to the products used and some to the individual user. Factors include product type and characteristics, how the products are used, including frequency of use, how the products are manufactured, who is using the product, and whether product characteristics are manipulated post-sale.

Toxicity is not the only factor in considering risk to an individual or a population from exposure to ENDS emissions. These factors may include the potential for abusing or manipulating the product, use by children and adolescents who otherwise would not have used cigarettes, simultaneous use with other tobacco products (dual or poly use) and children and adolescents going on to use smoked products following experimentation with ENDS. Further, not all ENDS are the same and the risks to health may differ from one product to another, and from user to user. (https://www.who.int/news-room/questions-and-answers/item/tobacco-e-cigarettes)

On the basis of the text presented here, any adult seeking to resolve their own uncertainty as to whether e-cigarettes are more or less harmful than combustible cigarettes would continue to be unsure as to whether e-cigarettes are indeed more or less harmful than combustible cigarettes with at least some adults smokers consulting the WHO website believing, on the basis of the text presented, that the strong discouragement to use either product is suggestive that both products must be equally harmful.

On the basis of the research reported here there is a clear need to ensure that adults who are smoking have access to the emerging science on what is known about the relative harms of combustible and non-combustible tobacco products. Importantly the need to ensure that accurate information on relative harm is conveyed to adults who are smoking remains even given concerns as to whether such a communication may provide a misplaced sense of confidence on the part of some population groups, including young people, resulting in their increased likelihood of using e-cigarettes and other non-combustion based tobacco products. The challenge facing public health bodies, and both national and international health authorities, is to find a way of conveying to adults who are smoking what the evidence on the relative harm of combustible and non-combustible tobacco products is showing whilst simultaneously discouraging use of these products by those who are not smoking.

Acknowledgements

The research reported in this paper was funded by British American Tobacco who had no role in the collection and interpretation of the data nor in the writing of this manuscript. The research reported here received a favourable ethics assessment from the Reading Independent Ethics Committee 11 Mar 2022

Action on Smoking and Health (2021) Available at https://ash.org.uk/resources/view/electronic-cigarettes

Bandi, P., Asare, S., Majmundar, A., Nargis, N., et al (2022 Relative Harm Perceptions of E-Cigarettes Versus Cigarettes, U.S. Adults, 2018-2020 Am J Prev Med Aug;63(2):186-194.

doi: 10.1016/j.amepre.2022.03.019. Epub 2022 Jun 8.

Brose, L., Brown, J., Hitchman, S., et al (2022) Perceived relative harm of electronic cigarettes over time and impact on subsequent use. A survey with 1-year and 2-year follow-ups Drug Alcohol Depend. 2015 Dec 1; 157: 106–111. doi: 10.1016/j.drugalcdep.2015.10.014

Delnevo, C., Jeong, M., Teotia, A., Bover, M., et al (2022) Communication Between US Physicians and Patients Regarding Electronic Cigarette Use. JAMA Network Open. 2022;5(4):e226692. doi:10.1001/jamanetworkopen.2022.6692

Food and Drug Administration (2021) FDA Permits Marketing of E-cigarette Products, Making First Authorization of its Kind by Agency available at https://WWW.FDA.Gov/News-Events/Press-announcement/FDA-Permits-Marketing-E-Cigarette-Products-Marking-First-Authorization-its-Kind

Hajek, P., Phllips-Waller, A., Przulj, D., Pesola, F., et al (2019) A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy New England Journal of Medicine 14;380(7):629-637.doi: 10.1056/NEJMoa1808779. Epub 2019 Jan 30.PMID: 30699054 DOI: 10.1056/NEJMoa1808779

He, H., Pan, Z., Wu, J., et al (2022) Health Effects of Tobacco at the Global, Regional, and National Levels: Results From the 2019 Global Burden of Disease Study Nicotine Tob Res 28;24(6):864-870.doi: 10.1093/ntr/ntab265.

Lam TH. 92012) Absolute risk of tobacco deaths: one in two smokers will be killed by smoking: comment on “Smoking and all-cause mortality in older people”. Archives of internal medicine. 2012;172(11):845–6. doi: 10.1001/archinternmed.2012.1927

Malt, L., Verron, T., Cahours,X., Guo, M., et al 2020) 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 Harm Reduct J. 2020; 17: 65. doi: 10.1186/s12954-020-00410-2PMCID: PMC7501702

Manderski, M., Steinberg, M., Wackowski, O., et al (2021) Persistent Misperceptions about Nicotine among US Physicians’ Results from a Randomized Survey Experiment. Int Jour of Environ Res and Pub Health 18 7713

McKee, M., Capewell, S. (2015) Electronic cigarettes: we need evidence, not opinions Lancet Volume 386, Issue 10000, 26 September–2 October 2015, Page 1239

Mok Y., Jeon, J., Levy D., Meza, R. (2022) Associations Between E-cigarette Use and E-cigarette Flavors with Cigarette Smoking Quit Attempts and Quit Success: Evidence From a U.S. Large, Nationally Representative 2018–2019 Survey Nicotine & Tobacco Research, ntac241, https://doi.org/10.1093/ntr/ntac241

Moysidou, A., Farsalinos, K., Voudris, V., et al (2016) Knowledge and Perceptions about Nicotine Replacement Therapies and Electronic Cigarettes Among Healthcare Professionals in Greece Int Jour Environ Res Pub Health. 13 514.

Office for Health Improvement and Disparities. Nicotine vaping in England: 2022 evidence update main findings 2022 [Available from: https://www.gov.uk/government/publications/nicotine-vaping-in-england-2022-evidence-update/nicotine-vaping-in-england-2022-evidence-update-main-findings.]

Public Health England (2015) E-cigarettes: an evidence update- A report commissioned by Public Health England

Royal College of Physicians. Nicotine without smoke: Tobacco harm reduction London: Royal College of Physicians; 2016 [Available from: https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction.

Royal College of General Practitioners and Cancer Research UK. RCGP Position Statement on the use of electronic nicotine vapour products (E-cigarettes) 2017 [Available from: https://www.cancerresearchuk.org/sites/default/files/rcgp_position_statement_on_the_use_of_electronic_nicotine_vapour_products.pdf.]

Singh, B., Hryna, M., Wackowski, O., Delnevo, C., Lewis, M., Steinberg M. (2017) Knowledge recommendation and beliefs of e-cigarettes among physicians involved in tobacco cessation: A qualitative study. Preventive Medicine Reports 8 25-29.

U.K. Gov (2021) E-cigarettes Could be Prescribed on the NHS in World First. Available at https://www.gov.uk/government/news/e-cigarettes-could-be-prescribed-on-the-nhs-in-world-first

U.K. Gov (2022) Nicotine Vaping in England:2022 evidence update including health risks and perceptions- a report commissioned by the office for Health Improvement and Disparities (authors McNeill, A., Simonavicius, E., Brose L., Taylor, E., East, K., et al) available at:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1107701/Nicotine-vaping-in-England-2022-report.pdf

World Health Organization Organization (2008) WHO report on the global tobacco epidemic, 2008: the MPOWER package. 2008.

Yong, H., Graveley, S., Borland, R., Gartner, C. et al (2022) 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 Nicotine Tob Res 6;24(9):1413-1421.doi: 10.1093/ntr/ntac087.

Table 1: Demographic Characteristics and Nicotine Product Use (n= 100)

Characteristics	n (%)
Gender
Male	40 (40%)
Female	60 (60%)
Age
21-30	25 (25.0%)
31-40	38 (38.0%)
41-50	22 (22.0%)
51-60 Mean (SD)	15 (15.0%) 38.4 (9.9)
Use of e-cigarettes
Ever used	62 (62.0%)
Use of Heated Tobacco Products (HTP)
Ever used	24 (24.0%)
Use of Nicotine Replacement Therapy (NRT)
Ever used	31 (31.0%)

Competing interest reported. The research reported in this paper was funded on the basis of a grant provided to the Centre for Substance Use Research by British American Tobacco. All authors of the manuscript submitted are employees of the Centre for Substance Use Research. The funding body for the study reported here had no role to play in the design of the research undertaken nor in the reporting of study findings which remained the responsibility of the authors.

Download PDF

Version 2

posted

You are reading this latest preprint version

Why Do Some Adults Who are Smoking Perceive E-cigarettes to be More Harmful than Combustible Cigarettes?

Status:

Version 2

Abstract

Introduction

Research Methods

Results

Discussion and Conclusions

Declarations

References

Tables

Additional Declarations

Status:

Version 2