Relative Harm Perceptions of E-Cigarettes Versus Cigarettes, U.S. Adults, 2018–2020


      It is unknown how U.S. adults’ relative harm perceptions of E-cigarettes versus cigarettes and associated behaviors changed during the E-cigarette or vaping product use‒associated lung injury epidemic (late 2019) and COVID-19 pandemic (since early 2020).


      Data from cross-sectional nationally representative Health Information National Trends Survey collected in 2018 (n=3,360), 2019 (n=3,217), and 2020 (n=3,677) (analyzed in 2021) were used to estimate changes in relative harm perceptions of E-cigarettes versus cigarettes (less harmful, as harmful, more harmful, don't know as a measure of uncertainty). In addition, changes in exclusive cigarette smoking, exclusive E-cigarette use, and dual use were estimated for each relative harm perception level.


      Perceptions of E-cigarettes as more harmful than cigarettes doubled year on year, increasing most between 2019 and 2020 (2018: 6.8%, 2019: 12.8%, 2020: 28.3%), whereas uncertainty in relative harm declined (2018: 38.2%, 2019: 34.2%, 2020: 24.7%). Less harmful relative perceptions declined (2018:17.6%, 2019:15.3%, 2020:11.4%), whereas as harmful perceptions remained steady (2018: 37.4%, 2019: 37.7%, 2020: 35.6%). Exclusive cigarette smoking increased between 2019 and 2020 among those who perceived E-cigarettes as relatively more harmful (2018: 18.5%; 2019: 8.4%; 2020: 16.3%), exclusive E-cigarette use increased linearly among those who perceived them as relatively less harmful (7.9%, 15.3%, 26.7%), and dual use increased linearly in those who perceived them relatively as harmful (0.1%, 1.4%, 2.9%).


      Perceptions of E-cigarettes as more harmful than cigarettes increased sharply between 2019 and 2020. Increases in tobacco product use were potentially guided by product-specific relative harm perceptions because changes occurred primarily in individuals who perceived their preferred product as relatively less harmful, suggesting the need for accurate messaging of relative and absolute product risks.
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        • Berry KM
        • Fetterman JL
        • Benjamin EJ
        • et al.
        Association of electronic cigarette use with subsequent initiation of tobacco cigarettes in U.S. youths.
        JAMA Netw Open. 2019; 2e187794
        • Miech R
        • Patrick ME
        • O'Malley PM
        • Johnston LD
        E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students.
        Tob Control. 2017; 26: e106-e111
        • Soneji S
        • Barrington-Trimis JL
        • Wills TA
        • et al.
        Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis.
        JAMA Pediatr. 2017; 171 ([published correction appears in JAMA Pediatr. 2018;172(1):92–93] [published correction appears in JAMA Pediatr. 2018;172(1):98] [published correction appears in JAMA Pediatr. 2020;174(5):509]): 788-797
        • Leventhal AM
        • Strong DR
        • Kirkpatrick MG
        • et al.
        Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence.
        JAMA. 2015; 314: 700-707
        • Neczypor EW
        • Mears MJ
        • Ghosh A
        • et al.
        E-cigarettes and cardiopulmonary health: review for clinicians.
        Circulation. 2022; 145: 219-232
        • National Academy of Sciences Engineering, and Medicine
        Public Health Consequences of E-Cigarettes.
        The National Academies Press, Washington, DC2018
        • Hartmann-Boyce J
        • McRobbie H
        • Butler AR
        • et al.
        Electronic cigarettes for smoking cessation.
        Cochrane Database Syst Rev. 2021; CD010216
      1. U.S. Department of Health and Human Services. Smoking cessation. A report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Published 2020. Accessed October 5, 2021.

        • Preventive Services Task Force U.S.
        • Krist AH
        • Davidson KW
        • et al.
        Interventions for tobacco smoking cessation in adults, including pregnant persons: U.S. Preventive Services Task Force recommendation statement.
        JAMA. 2021; 325: 265-279
        • Slovic P.
        Smoking: Risk, Perception, and Policy.
        SAGE Publications Inc, Thousand Oaks, CA2001
        • Romer D
        • Jamieson P.
        The role of perceived risk in starting and stopping smoking.
        in: Slovic P Smoking: Risk, Perception, and Policy. SAGE Publications Inc, Thousand Oaks, CA2001: 64-80
        • Hyland A
        • Li Q
        • Bauer JE
        • Giovino GA
        • Steger C
        • Cummings KM.
        Predictors of cessation in a cohort of current and former smokers followed over 13 years.
        Nicotine Tob Res. 2004; 6: S363-S369
        • Persoskie A
        • O'Brien EK
        • Poonai K.
        Perceived relative harm of using e-cigarettes predicts future product switching among U.S. adult cigarette and e-cigarette dual users.
        Addiction. 2019; 114: 2197-2205
        • Strong DR
        • Leas E
        • Elton-Marshall T
        • et al.
        Harm perceptions and tobacco use initiation among youth in Wave 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study.
        Prev Med. 2019; 123: 185-191
        • Elton-Marshall T
        • Driezen P
        • Fong GT
        • et al.
        Adult perceptions of the relative harm of tobacco products and subsequent tobacco product use: longitudinal findings from waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) study.
        Addict Behav. 2020; 106106337
        • Dave D
        • Dench D
        • Kenkel D
        • Mathios A
        • Wang H.
        News that takes your breath away: risk perceptions during an outbreak of vaping-related lung injuries.
        J Risk Uncertain. 2020; 60: 281-307
        • Delahanty J
        • Ganz O
        • Bernat JK
        • et al.
        Awareness of “The Real Cost” campaign among U.S. middle and high school students: National Youth Tobacco Survey, 2017.
        Public Health Rep. 2020; 135: 82-89
        • Huang J
        • Duan Z
        • Kwok J
        • et al.
        Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the U.S. retail e-cigarette market.
        Tob Control. 2019; 28: 146-151
      2. Outbreak of lung injury associated with the use of E-cigarette, or vaping, products. Centers for Disease Control and Prevention. Updated April 3, 2021. Accessed August 12, 2020.

        • Krishnasamy VP
        • Hallowell BD
        • Ko JY
        • et al.
        Update: characteristics of a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury - United States, August 2019 - January 2020.
        MMWR Morb Mortal Wkly Rep. 2020; 69: 90-94
        • Morgan JC
        • Silver N
        • Cappella JN.
        How did beliefs and perceptions about e-cigarettes change after national news coverage of the EVALI outbreak?.
        PLoS One. 2021; 16e0250908
        • Leas EC
        • Nobles AL
        • Caputi TL
        • et al.
        News coverage of the E-cigarette, or Vaping, product use Associated Lung Injury (EVALI) outbreak and internet searches for vaping cessation.
        Tob Control. 2021; 30: 578-582
        • Samet JM.
        Tobacco products and the risks of SARS-CoV-2 infection and COVID-19.
        Nicotine Tob Res. 2020; 22: S93-S95
        • Kamiński M
        • Muth A
        • Bogdański P.
        Smoking, vaping, and tobacco industry during COVID-19 pandemic: Twitter data analysis.
        Cyberpsychol Behav Soc Netw. 2020; 23: 811-817
        • Tiffany K.
        FDA shifts its COVID-19 stance on vaping, smoking impact.
        Bloomberg News. Bloomberg News, April 16, 2020
        • Majmundar A
        • Allem JP
        • Cruz TB
        • Unger JB.
        Public health concerns and unsubstantiated claims at the intersection of vaping and COVID-19.
        Nicotine Tob Res. 2020; 22: 1667-1668
        • Kavuluru R
        • Noh J
        • Rose SW.
        Twitter discourse on nicotine as potential prophylactic or therapeutic for COVID-19.
        Int J Drug Policy. 2022; 99103470
        • Huang J
        • Feng B
        • Weaver SR
        • Pechacek TF
        • Slovic P
        • Eriksen MP.
        Changing perceptions of harm of e-cigarette vs cigarette use among adults in 2 U.S. national surveys from 2012 to 2017.
        JAMA Netw Open. 2019; 2e191047
        • Majeed BA
        • Weaver SR
        • Gregory KR
        • et al.
        Changing perceptions of harm of e-cigarettes among U.S. adults, 2012-2015.
        Am J Prev Med. 2017; 52: 331-338
        • Yingst JM
        • Krebs NM
        • Bordner CR
        • Hobkirk AL
        • Allen SI
        • Foulds J.
        Tobacco use changes and perceived health risks among current tobacco users during the COVID-19 pandemic.
        Int J Environ Res Public Health. 2021; 18: 1795
        • Streck JM
        • Kalkhoran S
        • Bearnot B
        • et al.
        Perceived risk, attitudes, and behavior of cigarette smokers and nicotine vapers receiving buprenorphine treatment for opioid use disorder during the COVID-19 pandemic.
        Drug Alcohol Depend. 2021; 218108438
        • Rigotti NA
        • Chang Y
        • Regan S
        • et al.
        Cigarette smoking and risk perceptions during the COVID-19 pandemic reported by recently hospitalized participants in a smoking cessation trial.
        J Gen Intern Med. 2021; 36: 3786-3793
        • Yang Y
        • Lindblom EN
        • Salloum RG
        • Ward KD.
        Perceived health risks associated with the use of tobacco and nicotine products during the COVID-19 pandemic.
        Tob Induc Dis. 2021; 19: 46
        • White AM
        • Li D
        • Snell LM
        • et al.
        Perceptions of tobacco product-specific COVID-19 risk and changes in tobacco use behaviors among smokers, e-cigarette users, and dual users.
        Nicotine Tob Res. 2021; 23: 1617-1622
        • Kreslake JM
        • Diaz MC
        • Shinaba M
        • Vallone DM
        • Hair EC.
        Youth and young adult risk perceptions and behaviours in response to an outbreak of e-cigarette/vaping-associated lung injury (EVALI) in the USA.
        Tob Control. 2022; 31: 88-97
        • Tattan-Birch H
        • Brown J
        • Shahab L
        • Jackson SE.
        Association of the US outbreak of vaping-associated lung injury with perceived harm of e-cigarettes compared with cigarettes.
        JAMA Netw Open. 2020; 3e206981
      3. National Cancer Institute. Health Information National Trends Surveys Public Use Datasets: data terms of use. Updated July 22, 2021. Accessed May 14, 2021.

        • Ingram DD
        • Malec DJ
        • Makuc DM
        • et al.
        National Center for Health Statistics Guidelines for analysis of trends.
        Vital Health Stat 2. 2018; : 1-71
        • Blount BC
        • Karwowski MP
        • Morel-Espinosa M
        • et al.
        Evaluation of bronchoalveolar lavage fluid from patients in an outbreak of e-cigarette, or vaping, product use-associated lung injury -10 states, August-October 2019.
        MMWR Morb Mortal Wkly Rep. 2019; 68 ([published correction appears in MMWR Morb Mortal Wkly Rep. 2020;69(4):116]): 1040-1041
        • Kalkhoran SM
        • Levy DE
        • Rigotti NA.
        Smoking and e-cigarette use among U.S. adults during the COVID-19 pandemic.
        Am J Prev Med. 2022; 62: 341-349
        • Karanasos A
        • Aznaouridis K
        • Latsios G
        • et al.
        Impact of smoking status on disease severity and mortality of hospitalized patients with COVID-19 infection: a systematic review and meta-analysis.
        Nicotine Tob Res. 2020; 22: 1657-1659
        • Hou H
        • Li Y
        • Zhang P
        • et al.
        Smoking is independently associated with an increased risk for COVID-19 mortality: a systematic review and meta-analysis based on adjusted effect estimates.
        Nicotine Tob Res. 2021; 23: 1947-1951
        • Wang W
        • Huang Y.
        Countering the “harmless e-cigarette” myth: the interplay of message format, message sidedness, and prior experience with e-cigarette use in misinformation correction.
        Sci Commun. 2021; 43: 170-198
        • Svenson M
        • Green J
        • Maynard OM.
        Tackling smoker misperceptions about e-cigarettes using expert videos.
        Nicotine Tob Res. 2021; 23: 1848-1854
        • Hall MG
        • Saffer AJ
        • Noar SM.
        A secondary audience's reactions to “The Real Cost” advertisements: results from a study of U.S. young adult smokers and susceptible nonsmokers.
        Am J Prev Med. 2019; 56: S57-S64
      4. Hair EC, Kreslake JM, Rath JM, Pitzer L, Bennett M, Vallone D. Early evidence of the associations between an anti-e-cigarette mass media campaign and e-cigarette knowledge and attitudes: results from a cross-sectional study of youth and young adults. Tob Control. In press Online July 21, 2021.

        • Churchill V
        • Nyman AL
        • Weaver SR
        • Yang B
        • Huang J
        • Popova L.
        Perceived risk of electronic cigarettes compared with combustible cigarettes: direct versus indirect questioning.
        Tob Control. 2020; 30: 443-445
        • Maitland A
        • Lin A
        • Cantor D
        • et al.
        A nonresponse bias analysis of the Health Information National Trends Survey (HINTS).
        J Health Commun. 2017; 22: 545-553
      5. Leas EC, Moy NH, Nobles AL, Ayers J, Zhu SH, Purushothaman V. Google shopping queries for vaping products, JUUL and IQOS during the E-cigarette, or Vaping, product use Associated Lung Injury (EVALI) outbreak. Tob Control. In press. Online February 19, 2021.

        • U.S. Department of Health and Human Services
        U.S. Surgeon general issues advisory during COVID-19 vaccination push warning American public about threat of health misinformation.
        U.S. Department of Health and Human Services, Washington, DCJuly 15, 2021 (Accessed October 4, 2021)