E-cigarette Public Health Messaging Requires Nuance on Harms, Benefits

Jidong Huang, PhD

When it comes to the health impacts of electronic cigarettes, the truth is complicated. New research suggests the public might be missing the nuance, for better or worse.

Investigators from Georgia State University and the University of Oregon wanted to gain a better understanding of the extent to which public perception about e-cigarettes has changed over time. They used 2 large, nationally representative surveys—the Tobacco Products and Risk Perceptions Surveys (TPRPS) and the Health Information National Trends Surveys (HINTS)—to analyze changes in public perceptions from 2012 to 2017.

What they found was that the percentage of people who believe e-cigarettes are equally harmful to cigarettes increased substantially (from 11.5% to 36.4% in TPRPS), as did the number of people who believe e-cigarettes are more harmful than cigarettes (from 2.8% to 9.9% in HINTS). Though e-cigarettes have not been around long enough for scientists to fully understand the long-term health impacts of e-cigarette use, many public health agencies—including the Centers for Disease Control and Prevention—generally say e-cigarettes are somewhat less dangerous than cigarettes, even though they are still bad for the smoker’s health.

Corresponding author Jidong Huang, PhD, an associate professor in Georgia State’s School of Public Health, said there are multiple reasons why the public perception of e-cigarettes is out of step with the latest research. He said part of the problem might be a lack of understanding of the difference between absolute harm and relative harm.

“The confusion between the relative risk of e-cigarettes compared to cigarettes and the absolute risk of e-cigarettes may contribute to framing bias in media reports and press releases in which absolute harm is emphasized and relative harm is downplayed,” he told MD Magazine®.

The issue creates a conundrum for public health officials. Emphasizing relative risk could lead to the perception that e-cigarettes aren’t dangerous. Emphasizing absolute risk, though, could cause some people who might benefit from switching to e-cigarettes to avoid switching.

“Appropriate communication strategies will need to consider both the message content and the media channels, as well as the targeted audiences,” Huang said.

For messaging targeted at adults interested in quitting Huang said the message should be “quit all tobacco products, including e-cigarettes.”

“But for adult smokers who are unwilling or unable to quit, the appropriate message may be ‘a complete switch to e-cigarettes can reduce the health risks than continuing smoking cigarettes,’” he added.

However, there’s also another important audience when it comes to public health messaging: teenagers. In many regions, e-cigarettes have replaced cigarettes as the most common method of underage smoking.

In an editorial accompanying Huang’s study, Stanley A. Glantz, PhD, of the Center for Tobacco Control Research and Education, University of California, San Francisco, said research continues to pile up suggesting that e-cigarettes can increase the risk of a host of health problems, including myocardial infarction and chronic obstructive pulmonary disease (COPD). He argues that any public health messaging that gives teenagers the impression that e-cigarettes are safe—or even safer—is misguided.

“Youth who believe that e-cigarettes are not harmful or are less harmful than cigarettes are

more likely to use e-cigarettes than youth with more negative views of e-cigarettes,” Glantz wrote. “In terms of overall public health effects, this explosion of youth use swamps any potential harm reduction that may accompany adults switching from cigarettes to e-cigarettes.”

Huang agrees that the increase in teenage e-cigarette use is concerning. However, he said an overly simplified black-and-white view of e-cigarette risks could actually exacerbate the problem. He argues public health officials shouldn’t have to choose between accuracy and effectiveness, because the accurate message can also effective.

“If the general public, including teens, had an accurate and nuanced understanding of the health risks of e-cigarettes, they would know that for non-nicotine users, they will be better off not using any tobacco products, including e-cigarettes,” he said.

The study, “Changing Perceptions of Harm of e-Cigarette vs Cigarette Use Among Adults in 2 US National Surveys From 2012 to 2017,” and editorial, “The Evidence of Electronic Cigarette Risks Is Catching Up With Public Perception,” were published in JAMA Network Open.