This study reported:
- People's decisions to use e-cigarettes, as well as perceptions about associated risks, are influenced by the e-cigarettes' nicotine levels and available flavors.
- The influence of these characteristics on decision-making and perceived risk differs between people who smoke cigarettes and people who do not smoke.
- Regulating nicotine levels and flavors may help control e-cigarette use.
E-cigarettes (vapes, vaping) have become popular, especially among youth. Certain characteristics, such as availability of various flavors, as well as perceptions that e-cigarettes may be less harmful than combustible cigarettes, may promote their use. More recently, however, public health officials have raised concerns that use of e-cigarettes can be associated with serious health risks, including lung damage, impaired immune response, exposure to toxic chemicals, and nicotine dependence. A NIDA-sponsored study now indicates that regulation of nicotine levels and available flavors may help reduce initial and continued e-cigarette use. "As e-cigarette manufacturers continue to develop and modify their products to gain access to new user markets, new regulations must be considered to prevent new public health burdens, such as e-cigarette use among nicotine-naïve and particularly vulnerable groups such as youth," says Dr. Caroline Cobb, the study's senior investigator.
Ms. Cosima Hoetger, Dr. Cobb, and their colleagues at Virginia Commonwealth University conducted an online survey to determine how differences in potential regulatory action on e-cigarettes, including nicotine level, flavor, and messages regarding reduced health risks, influenced people's likelihood to try e-cigarettes and their perception of the potential harm caused by the devices. The researchers also evaluated whether the responses differed between those who already smoked cigarettes and nonsmokers.
A total of 706 participants were randomly assigned to read one of eight descriptions of e‑cigarettes that differed in terms of nicotine level (no nicotine, low nicotine, or high nicotine), flavor (tobacco, fruit, or menthol), and health risk message (reduced harm or reduced exposure to carcinogens). The participants were asked how likely they would be to use the described e-cigarettes and how harmful and addictive they thought the e-cigarettes would be. Additional questions allowed the researchers to determine the likelihood that each e‑cigarette condition might result in persistent use/dependence, by using a behavioral economic measure of abuse liability (see Figure).
Overall, survey responses suggested that differences in nicotine content and flavor had the greatest influence on all three outcomes assessed. For example, participants perceived e‑cigarettes with any nicotine level as being more harmful and addictive than those without nicotine. Also, compared with tobacco flavor e-cigarettes, those with menthol flavor were less likely to be used, had a lower abuse liability, and were also perceived as being more harmful.
However, people who currently smoke combustible cigarettes and nonsmokers responded differently to the e-cigarette characteristics assessed. Compared with nonsmokers, current smokers reported that they were more likely to try e-cigarettes, particularly those with high nicotine content and tobacco flavor. They were also more likely to use e-cigarettes presented with a message of reduced carcinogen exposure than ones with a reduced-harm message. In contrast, nonsmokers reported that they were more likely to try non-tobacco flavor e-cigarettes, suggesting that regulations that control flavor options may be particularly useful for protecting nonsmokers from initiating e-cigarette use. Dr. Cobb explains the relevance of these findings, saying, "Gauging the impact of potential regulations across user populations provides much-needed information to policymakers about the possible public health benefits or burden of new policy strategies aimed at tobacco products."
The study's findings may not be generalizable to the general population because participants were only recruited through Amazon's Mechanical Turk, which limited the survey to people with Internet access and an interest in the survey service and topic area. Nevertheless, the research team concluded that regulation of nicotine levels and flavors of e-cigarettes may help to control e-cigarette use. They also suggested that labeling, as well as health risk messages, will likely need to be tailored based on current smoking status of the target audience. "The growing popularity of e-cigarettes raises the importance of evidence-based regulatory policy, which has become increasingly necessary as we learn more about the negative health effects of e‑cigarettes as well as their potential role in smoking cessation," says Ms. Hoetger.
The findings may also aid other researchers in the field and smoking-related public health efforts. As Dr. Andrew Barnes, one of the investigators, explains, "As e-cigarette-related regulations try to keep pace with innovations in nicotine delivery and product marketing, our methods and results can help others in the field continue to advance tobacco regulatory science in the midst of an ever-evolving landscape. Ideally, tobacco regulatory science research can stay ahead of epidemics and inform regulations to avert public health crises."
This research was supported by NIDA grants DA043005 and DA036105.
- Text Description of Figure
The figure illustrates how researchers studied the relationship between e-cigarette characteristics and their influence on use, perceived harm, and potential for abuse. The eight colored boxes in the left half of the figure represent eight characteristics relating to nicotine content (blue boxes), flavor (gold boxes), and harm message (green boxes) that were presented to survey participants. Nicotine-content-related characteristics were high nicotine (dark blue), low nicotine (medium blue), and no nicotine (light blue); flavor-related characteristics were tobacco flavor (dark gold), fruit flavor (medium gold), and menthol flavor (light gold); and harm-message-related characteristics were reduced harm (dark green) and reduced carcinogen exposure (light green). A gray arrow in the middle points from the boxes representing the characteristics to a textbox on the right containing three questions that participants were asked after reading the e-cigarette descriptions. The top question assessed respondents’ susceptibility to using the described e-cigarettes; it reads, “How likely are you to use this e-cigarette soon, in the future, next year, or if offered by a friend?” The middle question assesses the respondents’ perception of harm and addiction associated with the described e-cigarette. It reads, “Compared to regular-strength non-menthol cigarettes, how harmful do you think this e-cigarette is? What do you think the likelihood of addiction is when using this e-cigarette?” The bottom question assesses the potential for abuse of the described e-cigarette. It reads, “How many times would you take 10 puffs of this e-cigarette if they were X dollars each?” For this question, the survey specified 16 price points from $0.00 to $10.24 per 10-puff bout.
- Hoetger, C., Bono, R.S., Nicksic, N.E., et al. Influence of electronic cigarette characteristics on susceptibility, perceptions, and abuse liability indices among combustible tobacco cigarette smokers and non-smokers. Int J Environ Res Public Health 16(10):E1825, 2019.