A total of 113 participants completed the web-based survey of which 103 participants attended the qualitative interview. Three interviewees were subsequently excluded from analyses because of inconsistencies in reports of their current smoking status. All interviews occurred between April 5, 2022, and June 27, 2022.
Quantitative Analysis
The demographic characteristics and nicotine product lifetime use for study participants are summarised in Table 1.
Table 1
Demographic characteristics and nicotine product (e-cigarettes, heated tobacco products, and NRT) lifetime use (n = 100)
Characteristics | n (%) |
Sex | |
Male | 40 (40%) |
Female | 60 (60%) |
Age | |
21–30 | 25 (25%) |
31–40 | 38 (38%) |
41–50 | 22 (22%) |
51–60 | 15 (15%) |
Mean (SD) | 38.4 (9.9) |
E-cigarettes or vaping products | |
Ever used | 62 (62%) |
Heated tobacco products | |
Ever used | 24 (24%) |
Nicotine Replacement Therapy (NRT) | |
Ever used | 31 (31%) |
Figure 2 shows respondents’ absolute harm perceptions of nine substances and products. Combustible cigarettes were viewed as ‘Very or extremely harmful’ by the largest proportion (76%) of those surveyed followed by alcohol (57%), nicotine (55%), marijuana (49%), fatty foods (36%), sugar (36%), e-cigarettes (33%), NRT (11%) and caffeine (5%). Very few respondents perceived any of the nine products and substances assessed as being ‘Not at all harmful"; with only 1% of respondents viewing combustible cigarettes as “Not at all harmful”, followed by alcohol (2%), fatty foods (2%), nicotine (3%), marijuana (3%), e-cigarettes (4%), sugar (5%), caffeine (7%), and NRT (8%). Approximately one in ten respondents (11%) didn’t know how harmful e-cigarettes were.
Figure 3 shows the relative ranking of the nine substances and products in terms of their perceived level of harm. Combustible cigarettes were perceived as being the most harmful of all the nine substances and products assessed, with e-cigarettes perceived as being less harmful than combustible cigarettes, alcohol, marijuana, nicotine, and fatty foods but more harmful than sugar, caffeine, and NRT.
Figure 4 shows the level of perceived harm of e-cigarettes relative to seven other substance and products assessed. Whilst the majority (59%) of respondents perceived e-cigarettes to be ‘Less harmful’ than combustible cigarettes, nevertheless around one in every four adults who smoke reported that e-cigarettes were as harmful, more harmful or didn’t know the harm in comparison to combustible cigarettes. Specifically, one in every five respondents (21%) viewed these devices as posing the same level of harm as combustible cigarettes, one in ten (9%) viewed e-cigarettes as being ‘More harmful’, and one in ten (11%) were unsure of where e-cigarettes and combustible cigarettes stood in relation to each other in terms of relative harm. Approximately one third (36%) viewed e-cigarettes as more harmful than NRT. Over two-thirds (64%) viewed e-cigarettes as being as harmful, more harmful, or not knowing the harm in relation to alcohol. These figures show very clearly that relative to a wide range of other substances and products, a significant proportion of respondents perceived e-cigarettes to be more harmful than these other substances.
Qualitative Data Analysis
Respondents who perceived e-cigarettes to be more harmful than combustible cigarettes offered an array of concerns to explain how they arrived at that view.
Scare Stories in the Media
Some interviewees drew attention to recent coverage in the news media citing various health harms which had been linked to e-cigarettes. Whilst some identified specific media stories illustrating the harms that e-cigarettes could cause, others seemed to cite media stories as having confirmed their pre-existing view that e-cigarettes were more harmful than people often assumed:
“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.” [Interview 88]
“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 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.” [Interview 88]
Concerns About Technology
Amongst those interviewees who perceived e-cigarettes to be more harmful than combustible cigarettes, attention was often drawn to concerns around the technological nature of vaping with some respondents contrasting the “non-natural” nature of vaping with what they saw to be the more “natural” use of burning tobacco leaves that occurs in smoking:
“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.” [Interview 52]
“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.” [Interview 52]
Frequency of Use
Interviewees drew attention to the greater frequency with which e-cigarettes would be used compared with combustible cigarettes, as a way of explaining why they felt these devices were more harmful than combustible cigarettes:
“I don’t think, well my friends 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.” [Interview 77]
In such cases, it was the perceived greater frequency with which e-cigarettes were likely to be used, rather than an implicit comparison of the two individual products, which caused e-cigarettes to be regarded as more harmful than combustible cigarettes.
Uncertainty Regarding the Impact of Long-Term Use
In explaining their thinking as to why e-cigarettes were more harmful than combustible cigarettes, several interviewees drew attention to the uncertainty over the harms associated with the long-term use of these devices. Some individuals commented on the length of time it had taken to fully appreciate the harms of smoking, believing that only with the passage of time would it become evident just how harmful e-cigarettes were:
“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 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.” [Interview 9]
“There you go. I know I’m inhaling nicotine, and everything bad for me. You don’t know 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.” [Interview 95]
Uncertainty About E-liquid Content
In explaining their thinking as to why e-cigarettes were more harmful than combustible cigarettes, 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.” [Interview 66]
“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.” [Interview 67]
“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.” [Interview 95]
E-cigarette Use Much Less Bounded
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 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.” [Interview 88]
Finally, it was evident that for a small number of interviewees the perception that e-cigarettes were less harmful than combustible cigarettes was itself seen as a possible cause of harm providing e-cigarette users with a misplaced sense of confidence in relation to the actual likely harms of vaping:
“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.” [Interview 88]
It is clear from the interviews that the perception of e-cigarettes as being more harmful than combustible cigarettes is based upon a good deal more than what is known about these products in the available published evidence. Indeed, what is perhaps most striking of all in these individuals’ accounts of the harms of e-cigarettes and combustible cigarettes was the lack of mention of the scientific evidence and the fact that these individuals had come to a view of the relative harm of these products by drawing upon a range of views, observations, speculations, media reporting, and fears.