In a recent study published in JAMA Network Open, researchers examined trends in the perception of harm caused by electronic cigarettes (e-cigarettes) relative to combustible cigarettes among smokers in England.

E-cigarettes are less harmful than cigarettes and can help people quit smoking. However, many adult smokers believe e-cigarettes to be as harmful as cigarettes. Various factors could have led to confusion regarding e-cigarettes. Media reporting has often exaggerated the risks of e-cigarettes, with evidence suggesting this might aggravate misperceptions.

Study: Trends in Harm Perceptions of E-Cigarettes vs Cigarettes Among Adults Who Smoke in England, 2014-2023. Image Credit: Andrey_Popov / Shutterstock

Risk messages can also influence harm perceptions. For instance, an outbreak of acute lung injuries in 2019 was misattributed to vaping even before the cause was identified and was labeled as e-cigarette or vaping product use-associated lung injury (EVALI). Further, concerns emerged that e-cigarettes may increase the risk of coronavirus disease 2019 (COVID-19) and its severity, albeit there was little evidence.

There have been short-term spikes in e-cigarette harm perceptions post-EVALI outbreak. Nevertheless, how harm perceptions of e-cigarettes evolved beyond 2020 and how the changes vary across population subgroups remains unclear. It is necessary to determine whether changes in perceptions have occurred over time among adult smokers because it has implications for accurate support and messaging.

About the study

In the present study, researchers explored the trends in harm perceptions of e-cigarettes in England relative to cigarettes. They obtained data from an ongoing cross-sectional survey of adults between November 2014 and June 2023. The sample was restricted to individuals aged 18 or older who were current smokers because the survey item assessing e-cigarette harm perceptions was limited to them.

Smokers were asked to specify their perception of whether e-cigarettes were less, more, or equally harmful to health as cigarettes. The primary outcome was the proportion of smokers who thought e-cigarettes were less harmful. Secondary outcomes included the proportions responding more harmful, equally harmful, or do not know.

Vaping status was determined with questions asking subjects if they used a vaping product or e-cigarette to quit or limit smoking or for other reasons. Those responding to e-cigarette use were deemed current vapers. The team applied logistic regression to evaluate associations between survey waves and perceptions of e-cigarettes.

Findings

Of over 169,400 individuals surveyed, 28,393 were current smokers, including 13,253 females. They were aged 43.5 on average, and 5,879 subjects were current vapers. Overall, 35.2% of smokers believed e-cigarettes were less harmful to health than cigarettes; 36.7% reported it as equally harmful, and 13.4% perceived it as more harmful, while 14.8% did not know.

Further, the proportion who perceived it was less harmful than cigarettes was higher among current vapers and the 35-64 age group. Nearly a third of dual users, i.e., smokers and vapers, perceived e-cigarettes as more or equally harmful. Moreover, significant changes occurred over time in harm perceptions. Specifically, in November 2014, the most common perception was that e-cigarettes were less harmful (44.4%); however, this view declined by 40% by June 2023.

The proportion of smokers who believed it was less harmful declined to 33.2% between November 2014 and July 2019, whereas the proportion who perceived it was equally harmful increased to 42.5%. Notably, there were marked shifts in perceptions in late 2019, with a sharp reduction in the proportion who believed it was harmful in the first quarter of 2020.

Meanwhile, the proportion believing e-cigarettes are more or equally harmful increased to 50.6%. The decrease in the proportion of smokers viewing e-cigarettes as less harmful was similar across age groups. The increase in the proportion of people believing e-cigarettes were more harmful was the most pronounced in the youngest age group. The proportion who thought e-cigarettes were less harmful was consistently lower among non-vapers.

Conclusions

In sum, harm perceptions of e-cigarettes among adult smokers in England have substantially worsened over the past decade. While the most common perception in 2014 was that e-cigarettes were less harmful, the proportion with this view declined by 40% by June 2023. On the other hand, the proportion who thought e-cigarettes were more harmful had more than doubled. Overall, currently, most adults who smoke and do not vape do not believe e-cigarettes are less harmful than cigarettes.