Abstract
Purpose:
Determine whether dual tobacco users have different levels of knowledge about nicotine addiction, perceived harm beliefs of low nicotine cigarettes (LNCs) and beliefs about electronic cigarettes (e-cigarettes)
Design:
Quantitative, Cross-sectional
Setting:
Health Information National Trends Survey 5 (Cycle 3, 2019)
Participants:
Nationally representative adult non-smokers (n=3113), exclusive cigarette smokers (n=302), and dual (cigarette and e-cigarette) users (n=77).
Measures:
The survey included single item measures on whether nicotine causes addiction and whether nicotine causes cancer. A five-point Likert scale assessed comparative harm of e-cigarettes and LNCs relative to conventional combustible cigarettes (1=much more harmful, 3=equally harmful…5 = much less harmful, or don’t know).
Analysis:
We used weighted multiple linear regression model to estimate means and 95% confidence intervals (CI) of e-cigarettes and LNCs beliefs by current tobacco user status.
Results:
Over 97% of dual users, 83% of non-smokers and 86% of exclusive cigarette smokers correctly identified that nicotine is addictive. The majority of subjects incorrectly identified nicotine as a cause of cancer, with dual users having the lowest proportion of incorrect responses (60%). Dual users rated e-cigarette harmfulness as less harmful than combustibles (mean=2.20; 95% CI=1.73, 2.66) while exclusive cigarette smokers and non-smokers rated them as similarly harmful. LNCs were considered equally harmful and addictive as conventional cigarettes.
Conclusion:
Dual users had a higher knowledge base of tobacco-related health effects. The effectiveness of policies or medical recommendations to encourage smokers to switch from cigarettes to LNCs or e-cigarettes will need to consider accurate and inaccurate misperceptions about the harm and addictiveness of nicotine. Improved public health messages about different tobacco products are needed.
Purpose
Tobacco smoking continues to be the major cause of premature mortality in the United States (U.S.). 1 Alternative tobacco products including electronic cigarettes (e-cigarettes) have adverse effects on the heart and lung, 2 but do not contain most of the harmful constituents in tobacco and tobacco smoke. 3 E-cigarettes have been marketed as a possible smoking cessation aid, which if successful could reduce tobacco-related morbidity and mortality. Low nicotine cigarettes (LNCs) contain less than 10% nicotine of conventional cigarettes (0.2 to 0.7 mg per cigarette). These products have recently been approved for sale (Moonlight and Moonlight Menthol cigarettes) but are not yet widely available. The labelling on LNCs does not claim benefits for improved health or lower addictiveness. Not using tobacco products is the best choice for all individuals and smokers who recognize the risks of conventional cigarettes are more likely to quit. 1 Clearly, knowledge of tobacco harm and addictiveness is important for tobacco control success and is assessed internationally by the Global Adult Tobacco Survey. 4 Increasing the awareness of tobacco knowledge is considered a key strategy for tobacco prevention and cessation. 5,6
With the increasing number of alternative tobacco products available to smokers such as e-cigarettes and LNCs, perceptions of these different products may vary depending on both the type of product, and how they are perceived relative to cigarettes. This may affect the choices of tobacco users in complex ways. Indeed, 27.7% of cigarette smokers were “dual users” of combustible cigarettes and e-cigarettes in 2018. 7
While youth should be discouraged from using any tobacco product, adults who continue to use tobacco have increasing choices to potentially reduce their tobacco-related harm and addiction. There is a need to understand their knowledge and perception of the relative properties of different tobacco products in a changing landscape of choices. Tobacco messaging and anti-tobacco messaging in regular and social media may result in uncertainty about the absolute and comparative benefits and harms of different products, and the efficacy of interventions at the population level will depend on accurate knowledge about the products. Dual use of e-cigarettes with cigarettes has remained stable since 2015, 7,8 likely due to the perception of e-cigarettes as a cessation aid. In HINTS 5, Cycle 3 (2019), we seek to assess knowledge and perceived knowledge about beliefs about product harm and addictiveness, and whether knowledge and beliefs vary based on the type of tobacco product currently used.
Methods
Design
This cross-sectional study used data from the Health Information National Trends Survey (HINTS). HINTS is a nationally representative survey targeted at ages 18 or older among United States adults. 9 HINTS is an ongoing survey designed to collect data on knowledge and attitudes on health information, and in particular cancer-related information. This information can be used to assess knowledge gaps and misperceptions, and allow health planners to improve the delivery of health-related information to the public. O’Brien et al. used the Health Information National Trends Survey (HINTS-FDA, 2015) to investigate U.S. adults’ addiction and harm beliefs about nicotine. 10 Three quarters of participants reported they were either unsure or mistakenly believed that nicotine is responsible for cancer. 10 Data collection for Cycle 3 of HINTS 5 began in January 2019 and concluded in April 2019. 9 The final sample consists of 5,438 subjects including 3,372 subjects who completed the survey on paper (the paper only group); 986 using the Web (“Web option, offering subjects a choice between responding via paper or web”); and 1,080 were in the Web bonus group (“Web bonus, offering subjects a choice between responding via paper or web with an additional $10 incentive for those responding via web”). 9 Additional information about HINTS are published elsewhere. 9
Sample
The current study focused on the current user status of participants, which results in a final analytic sample of non-smokers (n=3113), exclusive cigarette smokers (n=302), and dual users (n=77). Former smokers were excluded to allow for a comparison with a population from an earlier HINTS cycle. 10 Due to the small sample size (less than 30) of exclusive e-cigarette users, we did not include an e-cigarette exclusive group.
Measures
Demographic characteristics
Demographic variables included sex (male; female), age (18-34;35-49;50-64;65-74; 75 or older), race/ethnicity (non-Hispanic (NH) White; NH Black; Hispanic; NH other), educational attainment (less than high school; 12 years or completed high school; Some college; College graduate or higher), and household income ($0-$19,999; $20,000-$49,999; $50,000-$99,999; $100,000 or more).
Current user status
Subjects who smoked at least 100 cigarettes in their lifetime and currently smoke every day or some days were classified as smokers. 10 -12 Smokers were further classified as cigarette users only if they answered No to the question of “Have you ever used an e-cigarette, even one or two times?” Subjects were classified as never smokers if they had smoked less than 100 lifetime cigarettes 10,13,14 and had never used an e-cigarette. Dual users were defined as subjects who smoked at least 100 cigarettes in their lifetime, were currently smoking every day or some days, “ever used an e-cigarette, even one or two times”, 15 and were currently using an e-cigarette every day or some days.
Perceptions on nicotine harm and addictiveness
Subjects responded to questions on nicotine using a 4-point Likert scale ranging from strongly agree to strongly disagree, or responded don’t know. These included “Nicotine is the main substance in tobacco that makes people want to smoke” and “The nicotine in cigarettes is the substance that causes most of the cancer caused by smoking.”
Comparative harm perception of e-cigarettes
For the statement “New types of cigarettes are now available called electronic cigarettes or e-cigarettes (also known as vapes, vape-pens, tanks, mods or pod-mods). These products deliver nicotine through a vapor. Compared to smoking cigarettes, would you say that electronic cigarettes are…” much less harmful, less harmful, just as harmful, more harmful, much more harmful, or I don’t know.
Comparative harm perception of LNCs
For the statement “Compared to a typical cigarette, would you think that a cigarette advertised as low nicotine would be” much less/ slightly less/ equally/ slightly more/ much more harmful to your health than a typical cigarette. Don’t know was not included as a response option.
Comparative addiction perception of LNCs
The statement “Compared to a typical cigarette, would you think that a cigarette advertised as low nicotine would be” much less/ slightly less/ equally/ slightly more/ much more addictive than a typical cigarette.
Analysis
HINTS uses Taylor Series linearization variance estimation method to account for complex sample designs and to generate nationally representative estimates of statistical measures such as percentages and means. 9 Descriptive statistics of demographic and other measures were stratified by current user status including non-smokers, exclusive cigarette smokers, and dual users. Differences between these groups were analyzed using Chi-squared test. 9
The Likert-scaled responses to the statements on nicotine in cigarettes causes cancer and nicotine is the main addicting substance in tobacco were reclassified into three categories (e.g., correct, incorrect, and don’t know) to measure objective knowledge about nicotine since nicotine is the established addicting agent in tobacco, but is not a carcinogen. 1,10
However, for statements on the relative harmfulness of e-cigarettes compared to conventional cigarettes, widely publicized deaths linked to contaminated e-liquids, studies linking vaping to worsened pulmonary health 16 and remaining questions on the long-term effects of vaping creates uncertainty in comparisons to cigarette harm despite that cigarettes are established as the major cause of preventable deaths. Therefore, we categorized these responses as “belief” variables instead of classifying them as “knowledge”. 10
For the statements on the relative harmfulness of LNCs, LNCs contain nearly the same number of toxicants as conventional cigarettes although the public is likely unaware of the level of toxic constituents in LNCs. If smokers replaced conventional cigarettes with LNCs but continued to smoke LNCs at similar frequency for social or habitual reasons, their risks of disease would likely be similar to that from conventional cigarettes. There may be a benefit of lower nicotine in cigarettes on cardiovascular health but it is not established. 17 These responses were also classified as “belief” instead of “knowledge” variables.
Weighted multiple linear regression analyses were used to examine e-cigarette and LNCs beliefs among non-smokers, exclusive cigarette smokers, and dual users. We treated e-cigarette and LNCs beliefs responses as continuous variables and conducted a weighted analysis of variance (ANOVA) to investigate whether mean scores of e-cigarettes and LNCs beliefs were statistically different among these three groups (non-smokers, exclusive cigarette smokers, and dual users). The Bonferroni correction method was applied to adjust for multiple comparison. All analyses were conducted using SAS survey procedures, version 9.4 (SAS Institute) to account for the design effects of the complex survey data. All tests were two-sided with a significance level of 0.05.
Results
Demographic Characteristics by Current User Status
Table 1 lists the demographic characteristics of non-smokers, exclusive cigarette smokers, and dual users in HINTS 5, Cycle 3(2019). There were significant differences among non-smokers, exclusive cigarette smokers and dual users by age group, race, education, household income, and e-cigarette belief. Dual users were more likely to be non-Hispanic (NH) white, younger age group (18-34, 35-49), have a college degree or higher education compared to exclusive cigarette smokers (Table 1). More than 55% of dual users rated e-cigarettes much less harmful or less harmful compared to typical cigarettes, whereas less than 11% of non-smokers and exclusive cigarette smokers shared the same thought (Table 1).
Demographic Characteristics of Non-Smokers, Exclusive Cigarette Smokers, and Dual Users.
Note: Bolded p values indicate significance
1.Cigarette smokers: Exclusive cigarette smokers
2.Dual users: Smokers used both cigarettes and e-cigarettes
3.E-Cigarettes: New types of cigarettes are now available called electronic cigarettes or e-cigarettes (also known as vapes, vape-pens, tanks, mods or pod-mods). These products deliver nicotine through a vapor. Compared to smoking cigarettes, would you say that electronic cigarettes are:
Much less harmful/Less harmful/Just as harmful/More harmful/Much more harmful/I don’t know
Knowledge About Nicotine by Current User Status
Table 2 lists the knowledge about nicotine by current user status. More than 83% of non-smokers and exclusive cigarette smokers answered correctly (agree or strongly agree) to the question of nicotine is the main substance in tobacco that makes people want to smoke. For dual users, more than 97% of them answered correctly (Table 2). For the statement that nicotine causes cancer, dual users had the highest percentage of correct responses that nicotine does not cause cancer (disagree or strongly disagree; 40.40%), whereas non-smokers had the lowest percentage of correct responses (15.75%) and the highest percentage of don’t know responses (22.47%) compared to other tobacco product users (Table 2).
HINTS 5, Cycle 3(2019) Knowledge About Nicotine by Current User Status.
Comparative Harm Beliefs
From Table 1 data on the relative harmfulness of e-cigarette vs a typical cigarette, we calculated the mean score which resulted in values just above the scale’s midpoint (3.0) for both non-smokers and exclusive smokers, meaning that these subjects thought e-cigarettes were just as harmful as cigarettes (Table 3). The mean score is lower among dual users vs. exclusive cigarette users (2.20 vs. 3.02, p=0.0294) and vs. non-smokers (2.20 vs. 3.14, p=0.0011). There were no significant differences in the mean score of beliefs on the relative harmfulness of LNC vs. a typical cigarette between all three groups. Subjects rated LNCs as equally harmful compared to cigarettes (Table 3). Weighted multiple linear regression analyses of e-cigarette and, LNC harmfulness belief responses showed similar results (data not shown).
HINTS 5, Cycle 3(2019) Comparative Harm Beliefs by Current User Status.
Note:
a. New types of cigarettes are now available called electronic cigarettes or e-cigarettes (also known as vapes, vape-pens, tanks, mods or pod-mods). These products deliver nicotine through a vapor. Compared to smoking cigarettes, would you say that electronic cigarettes are much less/ much more harmful.
Response options ranged from1 (Much less harmful) to 5 (Much more harmful) with a midpoint of 3 (Just as harmful). “I don’t know” response is excluded from the linear regression analysis.
b. Response options ranged from1 (Much less harmful to your health than a typical cigarette) to 5 (Much more harmful to your health than a typical cigarette), with a midpoint of 3 (Equally harmful to your health).
c. Response options ranged from 1 (Much less addictive than a typical cigarette) to 5 (Much more addictive than a typical cigarette), with a midpoint of 3 (Equally addictive).
Comparing responses to beliefs on LNC addictiveness, no significant differences in mean scores were observed, with all three groups rating LNC addictiveness equal to cigarettes (Table 3).
Discussion
The data in this nationally-representative survey of adults found that while exclusive cigarette smokers had lower levels of education than non-smokers, dual users had similar levels of education as non-smokers. Dual users were more likely to be Non-Hispanic whites than other subjects. They were more likely to be younger than other subjects, reflecting lower income levels despite higher levels of education. About 85% of all subjects correctly identify that nicotine is the main substance that causes addiction. In dual tobacco users, 97% correctly identified nicotine as the addicting agent. These findings demonstrate a high degree of knowledge among nicotine addiction at the population-level. In contrast, the majority of subjects either answered incorrectly or were unsure about the association between nicotine and cancer. While this may seem surprising, only about 80% of physicians in a sample of American Medical Association members “strongly agreed” that nicotine contributes to the risk of cardiovascular disease, COPD, and cancer. 18 In the current study, dual users were more likely to correctly identify that nicotine was not a cancer causing substance.
Compared to non-smokers and exclusive cigarette smokers, dual users were more likely to rate e-cigarette as less harmful than a typical cigarette, which is consistent with results from the Population Assessment of Tobacco and Health (PATH) Study Wave 2 (percent of less harmful among dual users: 55% HINTS vs. 59% PATH). 19 Non-smokers and exclusive cigarette smokers were unsure or considered e-cigarettes just as harmful. This overall uncertainty may be due in part to how the public and specifically the survey respondents define harm. The concept of tobacco harm was developed by the Institute of Medicine in 2001 where tobacco harm reduction is based on the idea that reduced risk products for cigarette smokers will lower tobacco-related disease rates in smokers who cannot or don’t want to quit. 20 This concept is well established in the tobacco control community but the term may be vaguer in the general population or possibly thought as related to acute effects of tobacco. Improved tobacco messaging may be needed for improving public understanding of the risks and comparative risks of different tobacco products.
The relative harm of e-cigarettes vs conventional cigarettes from a tobacco control perspective is difficult to determine since there are no formal criteria. E-cigarettes are in all likelihood considerably less harmful because they contain much less
tobacco carcinogens. 21,22 One expert panel review estimated that e-cigarettes are 20 times less dangerous. 23 However, the long-term health effects of e-cigarette use remain unclear and need further investigation. 24 -26 Dual users are more highly educated than exclusive smokers and may be more informed on professional assessments of harm. Our results and PATH data differ from other studies on the harm perceptions of e-cigarettes. Whereas we found that most HINTS subjects were unsure or considered e-cigarettes just as harmful, most previous surveys found that e-cigarettes were perceived to be less harmful by the majority of participants. 27 This difference is not due to highly publicized findings of vaping associated lung injury, 28 which first occurred after the HINTS5 survey was completed. Whatever the reasons, it suggests that perceptions of these products can and do change over time.
Perceptions clearly are important in tobacco choices. U.S. adult dual users of e-cigarettes and cigarettes who perceive e-cigarettes as less harmful than cigarettes appear to be more likely to switch to exclusive e-cigarette use, and more likely to remain dual users than those who perceive e-cigarettes as harmful or more harmful than cigarettes. 19 This in turn may affect their levels of nicotine dependence. Dual use results in less cigarettes per day 29 but more severe craving and withdrawal symptoms, that contribute to further dependence on nicotine compared to exclusive cigarette smokers. 30 The effects of dual use with e-cigarettes appears to be somewhat greater than dual use with nicotine replacement therapy for cigarette reduction, but not for quit attempts. 29
It may not be entirely surprising that adults don’t think LNCs are less addictive given the history of low “yield” or “light” cigarettes being misleadingly advertised as safe or healthy alternatives. Yet there are substantial differences. “Light” cigarettes sold in past years still contain much higher levels of nicotine than the newer LNCs but this is likely not well understood. The marketing of new LNCs was approved in 2020 by the U.S. Food and Drug Administration under the assumption that such products don’t increase smoking exposure or smoking prevalence. It is expected that new LNCs products will potentially help smokers quit, or reduce smoking onset in youths although this will need to be demonstrated. Smokers will need to be informed about the differences between newer FDA-approved reduced nicotine products compared to the misleading advertised “light” or “low yield” products sold in previous years. However, new LNCs products are currently not labelled with their nicotine content or claims of less addictiveness. This underscores the challenges of proper messaging and proper perception of products. Switching smokers to non-addicting LNCs is potentially a major tobacco control policy but promoting LNCs as being less addictive is not warranted since it might encourage young people to start the smoking habit.
Taken in sum, our findings underscore that the public has both accurate and inaccurate perceptions about tobacco, and uncertainty about the relative safety of different tobacco products. Dual users had the highest percentage of correct answers on both knowledge questions (addictiveness of nicotine, and relationship between nicotine and cancer), whereas non-smokers had the lowest percentage of correct responses. Given legal constraints on tobacco product labelling, effective messaging will need to come from a variety of media sources. The content of such messages is not clear as the effects of e-cigarettes and LNCs on tobacco use patterns still need to be established. Until then, cessation with nicotine replacement and prevention messaging in youths remain the clear choice of tobacco messages even with misperceptions about tobacco harm.
Limitations
There are several limitations in this study. First, sample size for dual users is relatively limited and results may need to be interpreted with caution. We did not determine knowledge and beliefs in exclusive e-cigarette users due to the small sample size (less than 30). The HINTS 5 survey did not include a question on whether subjects perceived e-cigarettes as more or less addicting than regular cigarettes. This information would provide useful data on the motivations for using e-cigarettes. Another limitation is that there are other tobacco products such as cigars (little filtered, cigarillos), and hookah that were not measured in HINTS 5, Cycle 3. Information on their perceived harm compared to conventional cigarettes would allow for a broader understanding of tobacco use behaviors. Third, there were a limited number of items to measure knowledge about nicotine. Future study could use multiple items to have a further assessment of these beliefs. 10,15
So what?
What is already known on this topic?
Three quarters of participants from HINTS-FDA (2015) either were unsure or mistakenly believed that nicotine is responsible for cancer.
What does this article add?
Over 97% of dual users, 83% of non-smokers and 86% of exclusive cigarette smokers correctly identified that nicotine is addictive. The majority of subjects incorrectly identified nicotine as a cause of cancer, with dual users having the lowest proportion of incorrect responses (60%).
Dual users rated e-cigarette harmfulness scores significantly lower than other two groups, which may help to explain their use of both cigarettes and e-cigarettes given dual users’ perceptions on e-cigarettes being less harmful.
What are the implications for health promotion practice or research?
The effectiveness of policies or medical recommendations to encourage smokers to switch from cigarettes to LNCs or electronic cigarettes will need to consider accurate and inaccurate misperceptions about the harm and addictiveness of nicotine. Improved public health messages about different tobacco products are needed.
Footnotes
Author’s Note
This study used publicly available data HINTS 5, Cycle 3 (2019) from the National Cancer Institute (
). W. Lin conceptualized and designed the study, conducted statistical analyses, drafted the original manuscript. J. E. Muscat conceptualized and designed the study, reviewed and revised the manuscript, and approved the final manuscript as submitted.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.