Nicotine - Misperceptions, Misinformation, or Disinformation

Article: Difference: Misinformation, Disinformation, and Malinformation

• "Misinformation, disinformation, and malinformation are all terms that refer to false or misleading information, but they differ in how they are intentionally or unintentionally spread."

Fact Sheet: ASH brief addressing common myths about vaping

You might be interested in this companion wiki page: Information manipulation

Multi-National

Consumers

2023: Misconceptions of Vaping Among Young Adults

• Out of 1,009 participants most were from the United States, while succeeding countries included India (n = 40), Brazil (n = 10), Italy (n = 3), and seven other countries (n = 8).
• When asked whether smoking or vaping had more severe health implications, 55% of white or Caucasian participants, 41% of Asian participants, and 32% of black or African American participants indicated that vaping was worse than smoking cigarettes.

2022: Do smokers' perceptions of the harmfulness of nicotine replacement therapy and nicotine vaping products as compared to cigarettes influence their use as an aid for smoking cessation? Findings from the ITC Four Country Smoking and Vaping Surveys

• We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the United States.
• Consistent with past studies,our findings confirm that harm perceptions influence nicotine product use, with accurate perceptions associated with greater likelihood of use as a smoking cessation aid, whereas inaccurate perceptions appear to deter their use for this purpose.

2022: Exposure to Negative News Stories About Vaping, and Harm Perceptions of Vaping, Among Youth in England, Canada, and the United States Before and After the Outbreak of E-cigarette or Vaping-Associated Lung Injury (‘EVALI’)

• Between 2017 and February–March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained.

2021: Effects of brief exposure to misinformation about e-cigarette harms on twitter: a randomised controlled experiment

• This is the first study to explore the effect of exposure to misinformation about e-cigarette harms on Twitter, showing that after brief exposure to tweets that e-cigarettes are as or more harmful than smoking, current smokers may be deterred from using e-cigarettes (measured with intention to purchase e-cigarettes) as a harm reduction strategy. They are also more likely to wrongly believe that e-cigarettes are more harmful than regular cigarettes.
• The increasing trends of misperceptions about the relative harms of e-cigarettes compared with regular cigarettes are important for public health because perceived harms of e-cigarettes are associated with smokers' willingness to use e-cigarettes6 as a harm reduction strategy.

2020: Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries

• PDF of full report
• Between 68.3% (men, IN) and 88.7% (men, USA) of current consumers believed nicotine is harmful.
• Current consumers who agreed with the statement that nicotine is the primary cause of tobacco-related cancer ranged from 43.7% (men, UK) to 78.0% (men, SA).
• In six countries nicotine was rated nearly as harmful as cigarettes and alcohol...
• A reason why users of tobacco and THR products around the world find it hard to distinguish between the health risks of smoking and nicotine use may be due to conflicting messages from the media that deviate from the most recent scientific evidence base, overemphasize certain opinions or omit findings that do not align with their readers’ beliefs.
• We observed that the majority of current and previous product users estimated the harmfulness of nicotine and cigarettes alike. This has led to the misled conclusion that nicotine is responsible for the detrimental effects related to combustible tobacco consumption, even though science has found only very limited and often inconclusive evidence to date that nicotine is any more harmful than other legally consumed stimulants.
• Contradictory statements by leading researchers supported by renowned funding agencies and misreporting by the media may further public confusion as people have stated they use the media as a source of health information.

2020: Tobacco harm reduction in the 21st century

• These products have been subjected to regulatory bans and heavy taxation and are rejected by smokers and society based on misperceptions about nicotine, sensational media headlines...
• The misperception of the risks of these products results in smokers rejecting them, misperceptions that arise from inaccurate information and sensational media headlines. Public health officials are misinformed by these sources as well...
• These barriers will need to be addressed if tobacco harm reduction is to make the maximum impact on the tobacco endemic.

2020: Inequalities, harm reduction and non-combustible nicotine products: a meta-ethnography of qualitative evidence

• The review only identified studies exploring the attitudes of socioeconomically disadvantaged smokers towards NCNP (non-combustible nicotine products) for harm reduction or cessation purposes (i.e. we did not identify any relevant studies of more advantaged socioeconomic groups).
• Using a lines-of-argument meta-ethnographic approach, we identified a predominantly pessimistic attitude to NCNP for harm reduction or cessation of smoking due to:
  • wider circumstances of socioeconomic disadvantage;
  • lack of a perceived advantage of alternative products over smoking;
  • and a perceived lack of information about relative harms of NCNP compared to smoking.

2011: Nicotine replacement therapies: patient safety and persistence

• The exact role and effects of treatment may not be the only aspect of medication use that smokers are misinformed about: a number of studies have reported that a large proportions of smokers have concerns about the safety and efficacy of NRT products, believing either that these products do not promote cessation, that they are dangerous/ harmful to use, or that the mechanism of action of nicotine replacement products is to make a user sick if they lapse during treatment. Important for the purposes of this discussion, smokers who hold these misperceptions are less likely to have used NRT in the past, and less likely to say that they intend to use it as part of future quit attempts, suggesting that beliefs about NRTs’ safety and efficacy may impact on treatment use.

Health Care

2013: Survey of GPs' understanding of tobacco and nicotine products

• However, when asked to rank components of cigarettes based on their health risks, GPs ranked nicotine as the third riskiest (74 percent England, 87 percent Sweden), after tar and carbon monoxide, but before smoke or tobacco.
• Article: ‘GPs falsley believe nicotine most harmful cigarette ingredient’
  • ...less than half believe that long-term nicotine replacement therapy (NRT) is preferable to smoking (31% UK, 48% Sweden).
  • Many (44% UK, 56% Sweden) also wrongly believe that nicotine in tobacco products is associated with cancer, while 15% in the UK and 22% in Sweden believe the same for pharmaceutical nicotine.

Australia

Consumers

2023: Individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies relative to combustible cigarettes among people who smoke: Findings from the 2020 ITC Four Country Smoking and Vaping Survey

• Data analyzed came from 8,642 adults (18+ years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n=1213), Canada (n=2633), England (n=3057), and United States (US, n=1739).
• Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.

2022: Do smokers' perceptions of the harmfulness of nicotine replacement therapy and nicotine vaping products as compared to cigarettes influence their use as an aid for smoking cessation? Findings from the ITC Four Country Smoking and Vaping Surveys

• We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the United States.
• Consistent with past studies,our findings confirm that harm perceptions influence nicotine product use, with accurate perceptions associated with greater likelihood of use as a smoking cessation aid, whereas inaccurate perceptions appear to deter their use for this purpose.

2022: Clarifying Australia’s youth vaping figures

• The incorrect reporting of Australia’s purported ‘youth vaping epidemic’ has been used to argue for even tougher restrictions on access to nicotine vaping products. We should be restricting access to the nicotine product that causes the greatest harm in Australia, tobacco cigarettes. Cigarettes are still used by 2.9 million Australians who easily access them at retail outlets, despite being the leading preventable cause of disease burden.

2019: Nicotine vaping product use, harm perception and policy support among pharmacy customers in Brisbane, Australia

• There was widespread misperception about relative risk of nicotine-containing products, with 37% of respondents perceiving nicotine-containing NVPs to be as harmful as combustible cigarettes.

Healthcare

2019: Electronic nicotine delivery systems (e-cigarettes) as a smoking cessation aid: A survey among pharmacy staff in Queensland, Australia

• 24% of respondents believe e-cigarettes are equally as harmful as conventional cigarettes.

Canada

Consumers

2023: Individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies relative to combustible cigarettes among people who smoke: Findings from the 2020 ITC Four Country Smoking and Vaping Survey

• Data analyzed came from 8,642 adults (18+ years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n=1213), Canada (n=2633), England (n=3057), and United States (US, n=1739).
• Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.

2022: Do smokers' perceptions of the harmfulness of nicotine replacement therapy and nicotine vaping products as compared to cigarettes influence their use as an aid for smoking cessation? Findings from the ITC Four Country Smoking and Vaping Surveys

• We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the United States.
• Consistent with past studies,our findings confirm that harm perceptions influence nicotine product use, with accurate perceptions associated with greater likelihood of use as a smoking cessation aid, whereas inaccurate perceptions appear to deter their use for this purpose.

2022: Exposure to Negative News Stories About Vaping, and Harm Perceptions of Vaping, Among Youth in England, Canada, and the United States Before and After the Outbreak of E-cigarette or Vaping-Associated Lung Injury (‘EVALI’)

• Between 2017 and February–March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained.

China

Healthcare

2023: Doctors’ Survey: China results

• Physicians Have Misperceptions About Nicotine
• Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”
  • 92% - Nicotine causes atherosclerosis
  • 92% - Nicotine causes COPD
  • 91% - Nicotine causes lung cancer
  • 82% - Nicotine causes head/neck gastric cancers
  • 80% - Nicotine causes birth defects
  • 78% - Nicotine causes bladder cancer

France

Consumers

2023: Electronic cigarette: what perceptions in France?

• Article: 80% of French people believe that vaping causes cancer

2023: Vaping, nicotine: again and again, millions of French people are victims of the epidemic of doubt – Exclusive BVA survey for SOVAPE

• (summary coming soon!)

2022: TOBACCO HARM REDUCTION AND NICOTINE PERCEPTIONS

• People consume nicotine, but they die from smoking. Many consumers and doctors mistakenly believe that nicotine causes various illnesses, while it is proven that the many other toxins in smoking are the reason for them.
• 33% of smokers in France and 43% in Germany say that vaping is as harmful or more harmful than cigarettes and 6% of smokers in France and 21% of smokers in Germany say they don’t even know what vaping is.
• While 9% of smokers in both countries wrongly consider vaping the most harmful nicotine product, a staggering 11% of smokers perceive cigarettes as the least harmful product.
• 69% of smokers in France and 74% of smokers in Germany believe nicotine causes cancer.
• PDF of Report

Germany

Consumers

2022: TOBACCO HARM REDUCTION AND NICOTINE PERCEPTIONS

• People consume nicotine, but they die from smoking. Many consumers and doctors mistakenly believe that nicotine causes various illnesses, while it is proven that the many other toxins in smoking are the reason for them.
• 33% of smokers in France and 43% in Germany say that vaping is as harmful or more harmful than cigarettes and 6% of smokers in France and 21% of smokers in Germany say they don’t even know what vaping is.
• While 9% of smokers in both countries wrongly consider vaping the most harmful nicotine product, a staggering 11% of smokers perceive cigarettes as the least harmful product.
• 69% of smokers in France and 74% of smokers in Germany believe nicotine causes cancer.
• PDF of Report

Health Care

2023: Doctors' Survey: Germany results

• Physicians Have Misperceptions About Nicotine
• Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”
  • 83% - Nicotine causes atherosclerosis
  • 80% - Nicotine causes birth defects
  • 78% - Nicotine causes COPD
  • 78% - Nicotine causes head/neck gastric cancers
  • 77% - Nicotine causes lung cancer
  • 74% - Nicotine causes bladder cancer

2009: Medical students lack basic knowledge about smoking: Findings from two European medical schools

• A substantial number of students falsely assumed that nicotine causes coronary artery disease.

Greece

Consumers

2020: Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries

• PDF of full report
• Between 68.3% (men, IN) and 88.7% (men, USA) of current consumers believed nicotine is harmful.
• Current consumers who agreed with the statement that nicotine is the primary cause of tobacco-related cancer ranged from 43.7% (men, UK) to 78.0% (men, SA).
• In six countries nicotine was rated nearly as harmful as cigarettes and alcohol...
• A reason why users of tobacco and THR products around the world find it hard to distinguish between the health risks of smoking and nicotine use may be due to conflicting messages from the media that deviate from the most recent scientific evidence base, overemphasize certain opinions or omit findings that do not align with their readers’ beliefs.
• We observed that the majority of current and previous product users estimated the harmfulness of nicotine and cigarettes alike. This has led to the misled conclusion that nicotine is responsible for the detrimental effects related to combustible tobacco consumption, even though science has found only very limited and often inconclusive evidence to date that nicotine is any more harmful than other legally consumed stimulants.
• Contradictory statements by leading researchers supported by renowned funding agencies and misreporting by the media may further public confusion as people have stated they use the media as a source of health information.

Healthcare

2023: Doctors’ Survey: Greece results

• Physicians Have Misperceptions About Nicotine
• Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”
  • 74% - Nicotine causes atherosclerosis
  • 65% - Nicotine causes lung cancer
  • 64% - Nicotine causes COPD
  • 63% - Nicotine causes bladder cancer
  • 61% - Nicotine causes head/neck gastric cancers
  • 59% - Nicotine causes birth defects

India

Consumers

2020: Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries

• PDF of full report
• Between 68.3% (men, IN) and 88.7% (men, USA) of current consumers believed nicotine is harmful.
• Current consumers who agreed with the statement that nicotine is the primary cause of tobacco-related cancer ranged from 43.7% (men, UK) to 78.0% (men, SA).
• In six countries nicotine was rated nearly as harmful as cigarettes and alcohol...
• A reason why users of tobacco and THR products around the world find it hard to distinguish between the health risks of smoking and nicotine use may be due to conflicting messages from the media that deviate from the most recent scientific evidence base, overemphasize certain opinions or omit findings that do not align with their readers’ beliefs.
• We observed that the majority of current and previous product users estimated the harmfulness of nicotine and cigarettes alike. This has led to the misled conclusion that nicotine is responsible for the detrimental effects related to combustible tobacco consumption, even though science has found only very limited and often inconclusive evidence to date that nicotine is any more harmful than other legally consumed stimulants.
• Contradictory statements by leading researchers supported by renowned funding agencies and misreporting by the media may further public confusion as people have stated they use the media as a source of health information.

Healthcare

2023: Doctors’ Survey: India results

• Physicians Have Misperceptions About Nicotine
• Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”
  • 88% - Nicotine causes lung cancer
  • 87% - Nicotine causes atherosclerosis
  • 86% - Nicotine causes COPD
  • 78% - Nicotine causes head/neck gastric cancers
  • 75% - Nicotine causes birth defects
  • 71% - Nicotine causes bladder cancer

Indonesia

Healthcare

2023: Doctors’ Survey: Indonesia results

• Physicians Have Misperceptions About Nicotine
• Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”
  • 97% - Nicotine causes lung cancer
  • 92% - Nicotine causes COPD
  • 90% - Nicotine causes head/neck gastric cancers
  • 89% - Nicotine causes atherosclerosis
  • 89% - Nicotine causes birth defects
  • 87% - Nicotine causes bladder cancer

Israel

Healthcare

2023: Doctors’ Survey: Israel results

• Physicians Have Misperceptions About Nicotine
• Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”
  • 71% - Nicotine causes atherosclerosis
  • 69% - Nicotine causes bladder cancer
  • 69% - Nicotine causes lung cancer
  • 68% - Nicotine causes birth defects
  • 66% - Nicotine causes COPD
  • 65% - Nicotine causes head/neck gastric cancers

Italy

Healthcare

2023: Doctors’ Survey: Italy results

• Physicians Have Misperceptions About Nicotine
• Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”
  • 77% - Nicotine causes birth defects
  • 76% - Nicotine causes atherosclerosis
  • 69% - Nicotine causes COPD
  • 69% - Nicotine causes bladder cancer
  • 67% - Nicotine causes lung cancer
  • 64% - Nicotine causes head/neck gastric cancers

Japan

Consumers

2020: Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries

• PDF of full report
• Between 68.3% (men, IN) and 88.7% (men, USA) of current consumers believed nicotine is harmful.
• Current consumers who agreed with the statement that nicotine is the primary cause of tobacco-related cancer ranged from 43.7% (men, UK) to 78.0% (men, SA).
• In six countries nicotine was rated nearly as harmful as cigarettes and alcohol...
• A reason why users of tobacco and THR products around the world find it hard to distinguish between the health risks of smoking and nicotine use may be due to conflicting messages from the media that deviate from the most recent scientific evidence base, overemphasize certain opinions or omit findings that do not align with their readers’ beliefs.
• We observed that the majority of current and previous product users estimated the harmfulness of nicotine and cigarettes alike. This has led to the misled conclusion that nicotine is responsible for the detrimental effects related to combustible tobacco consumption, even though science has found only very limited and often inconclusive evidence to date that nicotine is any more harmful than other legally consumed stimulants.
• Contradictory statements by leading researchers supported by renowned funding agencies and misreporting by the media may further public confusion as people have stated they use the media as a source of health information.

Healthcare

2023: Doctors’ Survey: Japan results

• Physicians Have Misperceptions About Nicotine
• Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”
  • 89% - Nicotine causes atherosclerosis
  • 88% - Nicotine causes lung cancer
  • 88% - Nicotine causes COPD
  • 87% - Nicotine causes head/neck gastric cancers
  • 85% - Nicotine causes bladder cancer
  • 71% - Nicotine causes birth defects

Korea

Health Care

2017: Lung cancer specialist physicians' attitudes towards e-cigarettes: A nationwide survey

• We undertook a nationwide survey of pulmonologists, thoracic surgeons, medical and radiological oncologists who are members of Korean Association for Lung Cancer. Survey items included beliefs and attitudes toward e-cigarettes, attitudes toward e-cigarette regulation and preparedness on discussing e-cigarettes with their patients.
• Most respondents believed that e-cigarettes are not safer than conventional tobacco cigarettes (75.7%) or smokeless tobacco (83.2%), and feared that discussing e-cigarettes with the patients would encourage use (65.4%). They did not consider it a smoking cessation treatment (78.3%), and thus would not recommend it to smokers who do not want to quit (82.2%) or who failed to quit with conventional smoking cessation treatment (74.1%).
• Most learned about e-cigarettes from media and advertisements, or conversation with patients rather than through professional scientific resources, and reported discomfort when discussing e-cigarette with patients.

Kuwait

Consumers

2023: Prevalence of use, perceptions of harm and addictiveness, and dependence of electronic cigarettes among adults in Kuwait: A cross-sectional study

• Relative to cigarette smoking, 40.6% of participants reported that e-cigarettes are less harmful. 50.1% reported that e-cigarettes are associated with ‘much harm’.

Netherlands (Holland)

Consumers

2021: Regulation of e-cigarette flavours – a response

• Adopts false and misleading claims about the risks of e-cigarettes.
• Draws on irrelevant information about an outbreak of lung injuries in North America.
• Misunderstands “dual-use”.
• Asserts a “gateway effect” but there is more likely to be a diversion away from smoking.

New Zealand

Consumers

2010: Smokers commonly misperceive that nicotine is a major carcinogen: National survey data

• These findings are concerning since misperceptions about nicotine may result in underutilisation of NRT. Therefore, we aimed to assess these views in New Zealand (NZ) smokers, with the context being a country in which NRT is provided in a heavily subsidised form and widely distributed via the national quitline service.
• When asked if ‘the nicotine in cigarettes is the chemical that causes most of the cancer?’, most smokers in wave 1 (52.6%) said that it was true, 36.7% said it was false (the correct answer) and 10.7% could not say. The proportion answering ‘true’ was fairly similar in wave 2 at 52.1%. In a multivariate model (that adjusted for demographics, socioeconomic position, mental health and smoking-related beliefs and behaviours), certain groups of smokers were significantly more likely to believe that nicotine was carcinogenic. These included older smokers (≥50 vs <35 years); Māori smokers (vs European/other, adjusted OR (aOR)=1.77, 95% CI 1.22 to 2.58); and Asian smokers (vs European/other, aOR=3.25, 95% CI 1.35 to 7.83).

Norway

Consumers

2020: Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries

• PDF of full report
• Between 68.3% (men, IN) and 88.7% (men, USA) of current consumers believed nicotine is harmful.
• Current consumers who agreed with the statement that nicotine is the primary cause of tobacco-related cancer ranged from 43.7% (men, UK) to 78.0% (men, SA).
• In six countries nicotine was rated nearly as harmful as cigarettes and alcohol...
• A reason why users of tobacco and THR products around the world find it hard to distinguish between the health risks of smoking and nicotine use may be due to conflicting messages from the media that deviate from the most recent scientific evidence base, overemphasize certain opinions or omit findings that do not align with their readers’ beliefs.
• We observed that the majority of current and previous product users estimated the harmfulness of nicotine and cigarettes alike. This has led to the misled conclusion that nicotine is responsible for the detrimental effects related to combustible tobacco consumption, even though science has found only very limited and often inconclusive evidence to date that nicotine is any more harmful than other legally consumed stimulants.
• Contradictory statements by leading researchers supported by renowned funding agencies and misreporting by the media may further public confusion as people have stated they use the media as a source of health information.

Poland

Consumers

2021: The Frequency of Use and Harm Perception of Heated Tobacco Products (HTPs): The 2019 Cross-Sectional Survey among Medical Students from Poland

• Approximately half of the respondents believed they [HTPs] are safer than traditional cigarettes and almost 1/4 believed they are safer than e-cigarettes.

2021: Perception of Harmfulness of Various Tobacco Products and E-Cigarettes in Poland: A Nationwide Cross-Sectional Survey

• Among the respondents, 57.9% declared, that e-cigarette use causes serious diseases, with significant differences between smokers and non-smokers (60.4% vs. 49.1%, p = 0.01). Over a quarter of respondents (27.9%) did not know whether e-cigarette use causes disease. Lung cancer was the most common (65.8%) health effect of e-cigarette use indicated by the respondents. More than half of respondents believed that e-cigarette use causes stroke (54.4%) or myocardial infarction (59.4%), wherein non-smokers compared to smokers (p < 0.001) more often declared that e-cigarette use causes cardiovascular diseases.
• Among the respondents, 70% declared that e-cigarettes are as harmful as traditional cigarettes, wherein smokers compared to non-smokers more often declared that e-cigarettes are less harmful than traditional cigarettes (28.6% vs. 19.5%; p = 0.01). There were no statistically significant differences (p > 0.05) between smokers and non-smokers in the perception of the harmfulness of heated tobacco products. One-fourth of the respondents declared that smokeless tobacco is less harmful than traditional cigarettes with significant differences between smokers (32.3%) and non-smokers (22.9%; p = 0.01).

2017: How Social Care Beneficiaries in Poland Rate Relative Harmfulness of Various Tobacco and Nicotine-Containing Products

• The linear regression analysis indicated that relative to women, men consider slim cigarettes, smokeless tobacco and e-cigarettes to be more harmful than traditional cigarettes (p < 0.05).
• The smokers of traditional cigarettes reported menthol cigarettes to be less harmful than traditional cigarettes, relative to the non-smokers (p = 0.05).

2016: Perceived Relative Harm of Selected Cigarettes and Non-Cigarette Tobacco Products—A Study of Young People from a Socio-Economically Disadvantaged Rural Area in Poland

• The smokers of traditional cigarettes reported more harmfulness (compared to traditional cigarettes) in menthol, slim cigarettes, and e-cigarettes comparing to the non-smokers (p ≤ 0.03).

Health Care

2019: Knowledge and Beliefs of E-Cigarettes Among Physicians in Poland

• Among participants, 40.9% disagreed (“rather disagree” or “totally disagree”) that e-cigarettes are less harmful than conventional cigarettes.
• We have observed that only 21% of physicians get information about e-cigarettes from scientific articles. Most participants learned about e-cigarettes from non-scientific sources such as news stories or storefronts. Information obtained from such sources are not scientifically verified and might be biased. This poses a threat that education and guidance about e-cigarettes delivered by physicians is not based on evidence. Similar results were observed among healthcare providers’ in the US where the most frequently reported source of knowledge about e-cigarettes were patients (62%) or news stories (39%).

Saudi Arbia

Consumers

2023: Knowledge and Attitude toward E-Cigarettes among First Year University Students in Riyadh, Saudi Arabia

• When comparing e-cigarettes to regular cigarettes, 22.5% and 48.4% of the students agreed that they carry the same risk and have the same chemicals as normal cigarettes.

Healthcare

2021: Knowledge and Attitudes Among Medical Students Toward the Clinical Usage of e-Cigarettes: A Cross-Sectional Study in a University Hospital in Saudi Arabia

• Social media (77.4%) represented the primary source of information about e-cigarettes, followed by online (26.6%) and TV advertisements (9.8%)
• Only one-third of the respondents believed that e-smoking reduces the risk of cancer when used as an alternative to traditional cigarettes.

2019: E-cigarette use among medical students at Qassim University: Knowledge, perception, and prevalence

• Additionally, 44.9% of students believed that there is no reduction in cancer risk for e-cigarettes smokers.
• 41.9% of participants did not agree that e-cigarettes could help patients quit smoking, whereas the remaining participants 34.8% were not sure.
• The majority of students who received information about e-cigarettes outside medical school said they got the information from social media 74.7%, followed by 9.2% from online advertising, 4.4% from television advertisements, 0.4% each from radio advertisements, billboard and/or public signs. Other sources included newspapers or magazines 3.1% and other mediums 7.9%.

South Africa

Consumers

2020: Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries

• PDF of full report
• Between 68.3% (men, IN) and 88.7% (men, USA) of current consumers believed nicotine is harmful.
• Current consumers who agreed with the statement that nicotine is the primary cause of tobacco-related cancer ranged from 43.7% (men, UK) to 78.0% (men, SA).
• In six countries nicotine was rated nearly as harmful as cigarettes and alcohol...
• A reason why users of tobacco and THR products around the world find it hard to distinguish between the health risks of smoking and nicotine use may be due to conflicting messages from the media that deviate from the most recent scientific evidence base, overemphasize certain opinions or omit findings that do not align with their readers’ beliefs.
• We observed that the majority of current and previous product users estimated the harmfulness of nicotine and cigarettes alike. This has led to the misled conclusion that nicotine is responsible for the detrimental effects related to combustible tobacco consumption, even though science has found only very limited and often inconclusive evidence to date that nicotine is any more harmful than other legally consumed stimulants.
• Contradictory statements by leading researchers supported by renowned funding agencies and misreporting by the media may further public confusion as people have stated they use the media as a source of health information.

Healthcare

2023: Doctors' Survey: South Africa results

• Physicians Have Misperceptions About Nicotine

Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”

• • 82% - Nicotine causes lung cancer
  • 81% - Nicotine causes COPD
  • 62% - Nicotine causes birth defects
  • 57% - Nicotine causes atherosclerosis
  • 51% - Nicotine causes head/neck gastric cancers
  • 42% - Nicotine causes bladder cancer

Sweden

Consumers

2010: Harm perception among Swedish daily smokers regarding nicotine, NRT-products and Swedish Snus

• A majority, 59% of the answers to the question about harmfulness of NRT-products, and 75% of the answers about harmfulness of Snus, were inconsistent with the scientific evidence by demonstrating exaggerated perceptions of harmfulness. The strongest predictor of consistent answers was the perception of the harmfulness of nicotine.

Health Care

2013: Survey of GPs' understanding of tobacco and nicotine products

• However, when asked to rank components of cigarettes based on their health risks, GPs ranked nicotine as the third riskiest (74 percent England, 87 percent Sweden), after tar and carbon monoxide, but before smoke or tobacco.
• Article: ‘GPs falsley believe nicotine most harmful cigarette ingredient’
  • ...less than half believe that long-term nicotine replacement therapy (NRT) is preferable to smoking (31% UK, 48% Sweden).
  • Many (44% UK, 56% Sweden) also wrongly believe that nicotine in tobacco products is associated with cancer, while 15% in the UK and 22% in Sweden believe the same for pharmaceutical nicotine.

Turkey

Healthcare

2022: The Knowledge and Attitude about New Generation Tobacco Products among Physicians

• 72.5% Strongly Disagree - E-cigarettes and heated tobacco products are a safer alternative to traditional cigarettes as they provide a potential reduction in exposure to toxic substances.

United Kingdom or countries in the UK

Consumers

2023: Use of e-cigarettes (vapes) among adults in Great Britain

• Four in ten smokers incorrectly believe vaping is as or more harmful than smoking up from a third last year and one in five in 2019.
• A third of smokers understand that vaping is less harmful than smoking, but fewer than one in ten that they are a lot less harmful
• Ex-smokers who vape (2.9 million) have the most accurate perceptions of harm, with 75% correctly identifying that vaping is less harmful than smoking.
• From 2016 to 2019 the proportion of adults who inaccurately believed that vaping is as, or more harmful than smoking hovered around one in four, with between 43% and 50% believing it was less harmful. (Figure 8) However, in 2020 the proportion believing it was more or equally harmful rose significantly to 37% with the proportion believing it to be less harmful falling to 39%.
• The likely driver for this change in public perception was significant media coverage of injuries to health in the US from products banned in the UK. This years significant drop in public understanding that vaping is less harmful than smoking could be linked to widespread media coverage of youth vaping which has not always clearly distinguished the differences between the harms from smoking and vaping.
• In 2023 a third (34%) of smokers said that they did not know how harmful NRT is compared to smoking, 11% thought it was more than or equally as harmful as smoking, and only 29% correctly identified NRT as being a lot less harmful than smoking.

2023: Individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies relative to combustible cigarettes among people who smoke: Findings from the 2020 ITC Four Country Smoking and Vaping Survey

• Data analyzed came from 8,642 adults (18+ years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n=1213), Canada (n=2633), England (n=3057), and United States (US, n=1739).
• Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.

2022: Do smokers' perceptions of the harmfulness of nicotine replacement therapy and nicotine vaping products as compared to cigarettes influence their use as an aid for smoking cessation? Findings from the ITC Four Country Smoking and Vaping Surveys

• We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the United States.
• Consistent with past studies,our findings confirm that harm perceptions influence nicotine product use, with accurate perceptions associated with greater likelihood of use as a smoking cessation aid, whereas inaccurate perceptions appear to deter their use for this purpose.

2022: What are people’s views about the risks of vaping? Findings from conversations with the public.

• The graph (see website) shows that since 2013 there has been an increase in people inaccurately thinking that vaping is equally or more harmful than smoking among adults in Great Britain.
• People were asked what they thought was causing this increase in inaccurate beliefs:
  • ‘Youth vaping epidemic’ (the increase in youth vaping, particularly seen in the US) and increasing perceptions that vaping is for younger people
  • Misinformation about vaping (for example, that it can cause popcorn lung)
  • Negative news stories about vaping
  • Increasing disapproval of vaping
  • Vaping becoming the ‘new smoking’ (smoking becoming less prevalent while vaping becomes more prevalent, so there’s less to compare vaping to / less of a ‘negative comparison’)
  • Increasing discussions and education in school about ‘negative consequences of vaping’
  • Desensitisation to public health messaging about the reduced harm of vaping relative to smoking

2022: Myths and Misinformation: Mapping the barriers to smoking cessation and the uptake of nicotine alternatives

• ...with 93% of Brits overestimating the health risk of nicotine,...The over 60s and those from the lowest socio economic groups (C2DE) are the most likely to be misinformed...
• Our research has also revealed the scale of misunderstanding around vaping, with 90% of Brits’ responses ‘broadly incorrect’ about its harm compared to tobacco cigarettes; this despite public health evidence asserting that vaping is unlikely to exceed 5% of the harm that comes from smoking cigarettes.

2022: Exposure to Negative News Stories About Vaping, and Harm Perceptions of Vaping, Among Youth in England, Canada, and the United States Before and After the Outbreak of E-cigarette or Vaping-Associated Lung Injury (‘EVALI’)

• Between 2017 and February–March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained.

2022: The Khan review Making smoking obsolete

• However, there is lots of confusion, even misinformation, about vaping. The most common relates to its harm. I have spoken to the very best academics and scientists across the country and internationally. They all told me that vaping is far less harmful than smoking.
• In cigarettes, we know that it is not the nicotine that kills you but the other thousands of toxic chemicals such as tar and carbon monoxide. Vapes give smokers the nicotine they crave but protect them from the toxins they would inhale from a cigarette.

2021: Use of e-cigarettes (vapes) among adults in Great Britain

• Nearly two thirds of current vapers are ex-smokers (64.6%), and the proportion continues to grow, while the proportion who also smoke (known as dual users) has fallen to 30.5% in 2021.
• Fewer than 1% of never smokers are current vapers (amounting to 4.9% of vapers).
• As in previous years the main reason given by ex-smokers for vaping is to help them quit (36%) then to prevent relapse (20%).
• The main reason given by current smokers for vaping is to cut down (26%) then to help them quit (17%) and to prevent relapse (14%).
• Nearly a third of smokers incorrectly believe vaping is more or equally as harmful as smoking (32% compared to 34% in 2020).

2021: Video: Depression causes vaping!

• In this talk Professor Notley will discuss the latest evidence exploring associations between nicotine use and common mental health conditions, including depression.
• Interpretive assumptions will be drawn out, including inappropriate claims of causal relationships between vaping and depression.

2021: Effects of brief exposure to misinformation about e-cigarette harms on twitter: a randomised controlled experiment

• This is the first study to explore the effect of exposure to misinformation about e-cigarette harms on Twitter, showing that after brief exposure to tweets that e-cigarettes are as or more harmful than smoking, current smokers may be deterred from using e-cigarettes (measured with intention to purchase e-cigarettes) as a harm reduction strategy. They are also more likely to wrongly believe that e-cigarettes are more harmful than regular cigarettes.
• The increasing trends of misperceptions about the relative harms of e-cigarettes compared with regular cigarettes are important for public health because perceived harms of e-cigarettes are associated with smokers' willingness to use e-cigarettes6 as a harm reduction strategy.

2020: Association between changes in harm perceptions and e-cigarette use among current tobacco smokers in England: a time series analysis

• Between 2014 and 2019 in England, at the population level, monthly changes in the prevalence of accurate harm perceptions among current tobacco smokers were strongly associated with changes in e-cigarette use.
• For every 1% decrease in the mean prevalence of current tobacco smokers who endorsed the belief that e-cigarettes are less harmful than combustible cigarettes, the mean prevalence of e-cigarette use decreased by 0.48%

2020: Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries

• PDF of full report
• Between 68.3% (men, IN) and 88.7% (men, USA) of current consumers believed nicotine is harmful.
• Current consumers who agreed with the statement that nicotine is the primary cause of tobacco-related cancer ranged from 43.7% (men, UK) to 78.0% (men, SA).
• In six countries nicotine was rated nearly as harmful as cigarettes and alcohol...
• A reason why users of tobacco and THR products around the world find it hard to distinguish between the health risks of smoking and nicotine use may be due to conflicting messages from the media that deviate from the most recent scientific evidence base, overemphasize certain opinions or omit findings that do not align with their readers’ beliefs.
• We observed that the majority of current and previous product users estimated the harmfulness of nicotine and cigarettes alike. This has led to the misled conclusion that nicotine is responsible for the detrimental effects related to combustible tobacco consumption, even though science has found only very limited and often inconclusive evidence to date that nicotine is any more harmful than other legally consumed stimulants.
• Contradictory statements by leading researchers supported by renowned funding agencies and misreporting by the media may further public confusion as people have stated they use the media as a source of health information.

2019: Video: John Britton takes anti-vaping media to task

• E-cigarette Summit 2019
• John Britton, respiratory physician and Director of the UK Centre for Tobacco and Alcohol Studies at the University of Nottingham tells media and medical journals that when they publish hyperbolic stories about the harms of vaping they are sending people back to smoking and early death. Full video of Britton's E-cigarette Summit presentation available at vimeo.com/373905893

2019: Harm perceptions of e-cigarettes and other nicotine products in a UK sample

• Large proportions of UK smokers and ex-smokers overestimate the relative harmfulness of e-cigarettes and nicotine replacement therapy compared with smoking; misattributing smoking harms to nicotine is associated with increased misperceptions.
• eCancer Article: Misperceptions about vaping common among UK smokers
  • "Lead researcher Dr Leonie Brose, from the Institute of Psychiatry, Psychology & Neuroscience, said 'Tobacco cigarettes kill over half of those who smoke long-term, yet very few people know that nicotine is not the direct cause of smoking-related death and disease. We found those people who think nicotine is to blame for harms from smoking are more likely to think e-cigarettes and NRT are just as bad as smoking.'"
  • "Knowledge about nicotine was particularly poor, with nearly nine out of ten misattributing a greater portion of the risk in smoking to nicotine, and nearly four out of ten wrongly believing nicotine is what causes cancer from smoking."

2015: Nicotine “no more harmful to health than caffeine”

• Alarmingly RSPH research reveals that 90% of the public still regard nicotine itself as harmful and the organisation is now calling for measures to promote safer forms of nicotine products to smokers and make it harder to use tobacco.

Healthcare

2023: Doctors' Survey: UK results

• Physicians Have Misperceptions About Nicotine
• Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”
  • 65% - Nicotine causes atherosclerosis
  • 61% - Nicotine causes birth defects
  • 60% - Nicotine causes lung cancer
  • 59% - Nicotine causes COPD
  • 59% - Nicotine causes head/neck gastric cancers
  • 56% - Nicotine causes bladder cancer

2020: Electronic cigarettes as a smoking cessation aid for patients with cancer: beliefs and behaviours of clinicians in the UK

• Clinicians had sought information about e-cigarettes from...news/media/advertising (24%)...and charities (18%). Nineteen per cent of clinicians had never sought information about e-cigarettes.
• One-quarter of respondents (25%, n=124) were uncertain whether e-cigarettes were less harmful than smoking tobacco, while 10% (n=52) thought e-cigarettes were equally harmful or more harmful than smoking tobacco. Eighteen per cent (n=93) considered using e-cigarettes to be more harmful than regular nicotine replacement therapies (eg, gum, nasal spray, patches) and 54% (n=273) were uncertain.

2018: E-cigarettes as a Smoking Cessation aid in Cancer Patients: Health Professionals knowledge, attitude and current practice

• Over half of HPs believed their knowledge was not sufficient to recommend e-cigarettes to cancer patients, and 25% did not know whether e-cigarettes were less harmful than smoking tobacco cigarettes.

2013: Survey of GPs' understanding of tobacco and nicotine products

• However, when asked to rank components of cigarettes based on their health risks, GPs ranked nicotine as the third riskiest (74 percent England, 87 percent Sweden), after tar and carbon monoxide, but before smoke or tobacco.
• Article: ‘GPs falsley believe nicotine most harmful cigarette ingredient’
  • ...less than half believe that long-term nicotine replacement therapy (NRT) is preferable to smoking (31% UK, 48% Sweden).
  • Many (44% UK, 56% Sweden) also wrongly believe that nicotine in tobacco products is associated with cancer, while 15% in the UK and 22% in Sweden believe the same for pharmaceutical nicotine.

2009: Medical students lack basic knowledge about smoking: Findings from two European medical schools

• A substantial number of students falsely assumed that nicotine causes coronary artery disease.

United States

Consumers

2024: Harm perceptions of vaping nicotine relative to cigarette smoking among sexual and gender minority young adults

• "Moreover, findings illustrate that public health messages regarding the risks of e-cigarette use may have unintended consequences of increasing cigarette use to replace e-cigarette use for some SGM young adults, a practice that is incongruent with scientific evidence demonstrating that cigarettes and other combustible tobacco products are riskier than e-cigarettes and other forms of NT use."

2023: Older age is associated with greater misperception of the relative health risk of e-cigarettes and cigarettes among US adults who smoke

• Misperceptions about the absolute risks (ie, cigarettes are not harmful) and relative risks (ie, e-cigarettes are more harmful than cigarettes) of tobacco products may contribute to sustained smoking prevalence and hesitancy to switch from cigarettes to e-cigarettes among older adults.

2023: Change in E-cigarette risk perception and smoking behavior of Black and Latinx individuals who smoke.

• Results: The mean CPW [Cigarettes Smoked Per Week] decreased from 82.8 (SD=49.8) at baseline to 15.8 (SD=29.8) at week 6. A one-level increase in EC [E-cigarette] risk perception (i.e., EC perceived as riskier than CC [Combustible Cigarettes] from baseline to week 6) was associated with an increase in CPW (IRR: 1.83, 95% CI: 1.03; 3.24). Latinx participants were more likely to have higher CPW as EC risk perception increased compared to Black participants (IRR=1.89, 95% CI: 1.09; 3.26).

2023: Perceptions about Levels of Harmful Chemicals in E-cigarettes Relative to Cigarettes, and Associations with Relative E-cigarette Harm Perceptions, E-cigarette Use and Interest

• In the United States, most adults who smoke cigarettes and young adult non-smokers do not appear to think that e-cigarettes have fewer harmful chemicals than cigarettes, and many are uncertain about how these levels compare.

2023: Individual and conjoint factors associated with beliefs about the harmfulness of nicotine replacement therapies relative to combustible cigarettes among people who smoke: Findings from the 2020 ITC Four Country Smoking and Vaping Survey

• Data analyzed came from 8,642 adults (18+ years) who smoked daily/weekly and participated in the 2020 ITC Four Country Smoking and Vaping Survey in Australia (n=1213), Canada (n=2633), England (n=3057), and United States (US, n=1739).
• Many people who regularly smoke cigarettes are unaware that NRTs are much less harmful than cigarettes. Additionally, beliefs about NRTs relative harmfulness appear to be influenced by both individual and conjoint factors.

2023: Over 1 year later: smokers’ EVALI awareness, knowledge and perceived impact on e-cigarette interest

• Despite the passage of time, considerable lack of knowledge and misperceptions about EVALI remain among those who smoke. Our findings suggest the need for continued efforts to promote better understanding of EVALI and appropriate behavioural and policy responses.

2022: Unintended Consequences: Testing the Effects of Adolescent-Targeted Anti-Vaping Media upon Adult Smokers

• Sensationalized youth-oriented anti-vaping messages may have unintended public health consequences upon adult audiences.
• Exposure to the PSA resulted in overall more negative expectancies about e-cigarettes, as well as increased perceived harmfulness and reduced effectiveness of e-cigarettes for smoking cessation. Findings showed that these PSAs could deter adult smokers from utilization of e-cigarettes as a smoking cessation or harm reduction strategy.

2022: Relative Harm Perceptions of E-Cigarettes Versus Cigarettes, U.S. Adults, 2018–2020

• Perceptions of E-cigarettes as more harmful than cigarettes doubled year on year, increasing most between 2019 and 2020...
• Exclusive cigarette smoking increased between 2019 and 2020 among those who perceived E-cigarettes as relatively more harmful...
• ...dual use increased linearly in those who perceived them relatively as harmful...
• Article: Vaping Safety Views Shifted Following Lung Injury Reports
  • The main finding that people started smoking cigarettes when they thought e-cigarettes were more harmful should be a wake-up to public health officials and doctors...
  • The new study showed a sharp change in public perception of e-cigarettes following media coverage of cases of users who presented to emergency rooms with mysterious lung symptoms (EVALI) in 2019.

2022: Do smokers' perceptions of the harmfulness of nicotine replacement therapy and nicotine vaping products as compared to cigarettes influence their use as an aid for smoking cessation? Findings from the ITC Four Country Smoking and Vaping Surveys

• We analyzed data from 1,315 current daily smokers (10+ cigarettes per day) who were recruited at Wave 1 (2016), and who reported making a quit attempt by Wave 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England, and the United States.
• Consistent with past studies,our findings confirm that harm perceptions influence nicotine product use, with accurate perceptions associated with greater likelihood of use as a smoking cessation aid, whereas inaccurate perceptions appear to deter their use for this purpose.

2022: Exposure to Negative News Stories About Vaping, and Harm Perceptions of Vaping, Among Youth in England, Canada, and the United States Before and After the Outbreak of E-cigarette or Vaping-Associated Lung Injury (‘EVALI’)

• Between 2017 and February–March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained.

2022: Beliefs and Characteristics Associated With Believing Nicotine Causes Cancer: A Descriptive Analysis to Inform Corrective Message Content and Priority Audiences

• About 61.2% of smokers believe nicotine causes cancer or don't know.
• High perceived threat of tobacco may be overgeneralized to nicotine. High prevalence of the misperception among Non-Hispanic Black and low-income smokers is concerning, considering existing health disparities. Messaging should attempt to correct the misperception that nicotine causes cancer.

2022: Audio: Cliff Douglas on WOSU

• Misinformation, continuum of risk, etc.

2022: A Close Look at Vaping in Adolescents and Young Adults in the USA

• Public mistrust about ECs is exacerbated by the spread of misinformation and distortion of scientific truth.
• Although EC use by young non-smokers is a legitimate concern, known risks from vaping are often greatly exaggerated; common misconceptions about EC use and the evidence to refute these misconceptions have been summarized in Table 2

2022: Opinion: A Bold U.K. Plan to End the Smoking Epidemic

• Youth vaping is no longer an "epidemic." But these efforts, which too often inaccurately portray the risks of e-cigarettes, have led to significant public misunderstanding regarding the substantially lower health risks of e-cigarettes compared to combustible tobacco products. This, in turn, has impeded the promotion of tobacco harm reduction to the more than 30 million adults who still smoke.
• Nicotine causes dependency but does not itself cause the many diseases resulting from the inhalation of burned tobacco, a fact misunderstood by the majority of physicians...

2022: In vivo Experience With NRT to Increase Adherence and Smoking Abstinence Among Individuals in the Criminal Legal System: Study Protocol for a Randomized Clinical Trial

• Nicotine replacement therapy (NRT) is a relatively effective and accessible smoking cessation aid; however, individuals frequently stop use of NRT early due to side effects and misperceptions about the products.
• The in vivo group uses NRT in session and discusses perceptions and experiences of using NRT in real time...

2022: Google shopping queries for vaping products, JUUL and IQOS during the E-cigarette, or Vaping, product use Associated Lung Injury (EVALI) outbreak

• Objectives: To assess whether the late 2019 US outbreak of pulmonary disease linked to vaping ('E-cigarette, or Vaping, product use Associated Lung Injury' (EVALI)) impacted online shopping queries for vaping products and the Philip Morris 'IQO' brand of heated tobacco.
• Results: During the outbreak, vape shopping queries were 34% (95% CI 30% to 38%) lower than expected and JUUL shopping queries were 39% (95% CI 34% to 45%) lower than expected, translating into about 7.2 and 1.0 million fewer searches. IQOS shopping queries were 58% (95% prediction interval (PI): 34-87) higher than expected, translating into 35 000 more searches. Moreover, IQOS shopping queries reached a historic high the week they were discussed as a potentially safe alternative to vaping (the week of 29 September 2019), when they were 382% (95% PI: 219-881) above expected rates for the week.
• Note from the Safer Nicotine Wiki team: EVALI during the time of this study was being incorrectly blamed on nicotine vapor products. IQOS is a heated tobacco product, not a traditional vapor product.

2022: Perceptions of E-cigarettes among adults in treatment for opioid use disorder

• Nonetheless, a sizable proportion of participants in our sample rated e-cigarettes as harmful and rated e-cigarettes as more or equivalently harmful as cigarettes. Our findings align with recent work in the general population demonstrating increases in perceived harm of e-cigarettes following EVALI

2021: Associations Between Nicotine Knowledge and Smoking Cessation Behaviors Among US Adults Who Smoke

• This study provides longitudinal evidence that among adult smokers, misperceiving nicotine as a primary cause of smoking-related diseases may be associated with reduced cessation success and lower likelihood of using less harmful nicotine products. These misperceptions may therefore impede efforts to encourage smokers ready to quit to use evidence-based cessation support such as nicotine replacement during quit attempts and limit the success of policies designed to shift smokers to less harmful sources of nicotine.

2021: Balancing Consideration of the Risks and Benefits of E-Cigarettes

• Many US governmental health agencies and nongovernmental medical and health organizations focus primarily on vaping’s risks for young people. These organizations’ pronouncements and their influence on policymakers and the media have had a profound impact on the public’s understanding of vaping.
• A study of US news articles on e-cigarettes found that, from 2015 to 2018, 70% of articles mentioned vaping’s risks for youths, while only 37.3% noted potential benefits for adult smokers.
• Unfortunately, the public has a distorted view of the dangers associated with nicotine per see. Of respondents to a 2019 national survey, nearly half considered vaping nicotine just as harmful as or more harmful than cigarette smoking. Only 1 in 8 considered vaping less harmful.
• The public’s inaccurate perception worsened following a 2019 vaping-associated acute pulmonary disease outbreak [EVALI]...research attributed the illness to vitamin E acetate, an adulterant in illicit tetrahydrocannabinol (THC) vaping devices...Yet, after the outbreak, two thirds of respondents to a poll related the lung disease deaths to use of “e-cigarettes such as JUUL.” Only 28% related the deaths to use of “marijuana or THC e-cigarettes.”
• In a recent survey of physicians, 80% strongly, but incorrectly, agreed that nicotine causes cancer, cardiovascular disease, and chronic obstructive pulmonary disease.

2021: Video: Depression causes vaping!

• In this talk Professor Notley will discuss the latest evidence exploring associations between nicotine use and common mental health conditions, including depression.
• Interpretive assumptions will be drawn out, including inappropriate claims of causal relationships between vaping and depression.

2021: Effects of brief exposure to misinformation about e-cigarette harms on twitter: a randomised controlled experiment

• This is the first study to explore the effect of exposure to misinformation about e-cigarette harms on Twitter, showing that after brief exposure to tweets that e-cigarettes are as or more harmful than smoking, current smokers may be deterred from using e-cigarettes (measured with intention to purchase e-cigarettes) as a harm reduction strategy. They are also more likely to wrongly believe that e-cigarettes are more harmful than regular cigarettes.
• The increasing trends of misperceptions about the relative harms of e-cigarettes compared with regular cigarettes are important for public health because perceived harms of e-cigarettes are associated with smokers' willingness to use e-cigarettes6 as a harm reduction strategy.

2021: E-Cigarette Use and Perceptions Among Veterans Receiving Outpatient Treatment in Veterans Affairs Substance Use and Mental Health Clinics

• 36% of study participants falsely believed vaping was as harmful as smoking.

2021: Opinion Michael Madden, MD: Misinformation Threatens Efforts to Reduce Tobacco Harm

• Their well-intentioned but misguided and unscientific beliefs, however, may actually reap a consequence they certainly do not intend: increased youth cigarette smoking.
• Yet many government regulators and elected officials have allowed misinformed and misguided activists who refuse to discuss the science behind tobacco harm reduction to take the reins on this vital public health issue, while in other countries (Great Britain and New Zealand, for example), governments leverage tobacco harm reduction strategies to save lives.

2020: Perception of the relative harm of electronic cigarettes compared to cigarettes amongst US adults from 2013 to 2016: analysis of the Population Assessment of Tobacco and Health (PATH) study data

• In this study, the proportion of US adults who incorrectly perceived e-cigarettes as equal to, or more, harmful than cigarettes increased steadily regardless of smoking or vaping status.
• Current adult smokers appear to be poorly informed about the relative risks of e-cigarettes yet have potentially the most to gain from transitioning to these products.
• The findings of this study emphasise the urgent need to accurately communicate the reduced relative risk of e-cigarettes compared to continued cigarette smoking and clearly differentiate absolute and relative harms.

2020: Association of the US Outbreak of Vaping-Associated Lung Injury With Perceived Harm of e-Cigarettes Compared With Cigarettes

• After the US outbreak of vaping-associated lung injury, views on e-cigarettes among smokers in England deteriorated. The proportion perceiving e-cigarette use as less harmful than cigarette smoking decreased, and the proportion perceiving e-cigarette use as more harmful increased by over one-third.
• Citation: 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;3(6):e206981. doi:10.1001/jamanetworkopen.2020.6981

2020: NEWS THAT TAKES YOUR BREATH AWAY: RISK PERCEPTIONS DURING AN OUTBREAK OF VAPING-RELATED LUNG INJURIES

• The increase in e-cigarette risk perceptions might discourage adult smokers from using e-cigarettes as a way to quit smoking, despite evidence from a clinical trial that ecigarettes are a more effective cessation method than FDA-approved products such as the nicotine patch.
• Our econometric results suggest that the immediate impact of the first information shock was to increase the fraction of respondents who perceived e-cigarettes as more harmful than smoking by about 16 percentage points. More targeted advice about the risks of THC e-cigarettes (vs nicotine products) might have more effectively reduced the use of those products, potentially preventing EVALI cases.
• PDF Version
• Citation: Dave, D., Dench, D., Kenkel, D. et al. News that takes your breath away: risk perceptions during an outbreak of vaping-related lung injuries. J Risk Uncertain 60, 281–307 (2020). doi: 10.1007/s11166-020-09329-2
• Acknowledgement: Dhaval Dave acknowledges support through grant R01DA039968 from the National Institute on Drug Abuse. The authors are grateful to Cornell University and the Health Thought Leadership Network at Bentley University for funding the data collection.

2020: Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries

• PDF of full report
• Between 68.3% (men, IN) and 88.7% (men, USA) of current consumers believed nicotine is harmful.
• Current consumers who agreed with the statement that nicotine is the primary cause of tobacco-related cancer ranged from 43.7% (men, UK) to 78.0% (men, SA).
• In six countries nicotine was rated nearly as harmful as cigarettes and alcohol...
• A reason why users of tobacco and THR products around the world find it hard to distinguish between the health risks of smoking and nicotine use may be due to conflicting messages from the media that deviate from the most recent scientific evidence base, overemphasize certain opinions or omit findings that do not align with their readers’ beliefs.
• We observed that the majority of current and previous product users estimated the harmfulness of nicotine and cigarettes alike. This has led to the misled conclusion that nicotine is responsible for the detrimental effects related to combustible tobacco consumption, even though science has found only very limited and often inconclusive evidence to date that nicotine is any more harmful than other legally consumed stimulants.
• Contradictory statements by leading researchers supported by renowned funding agencies and misreporting by the media may further public confusion as people have stated they use the media as a source of health information.

2019: Changing Perceptions of Harm of e-Cigarette vs Cigarette Use Among Adults in 2 US National Surveys From 2012 to 2017

• In 2 nationally representative multiyear cross-sectional surveys of US adults, the proportion who perceived e-cigarettes to be as harmful as or more harmful than cigarettes increased substantially from 2012 to 2017.
• Given the demonstration by previous studies that perception of risk plays a critical role in decisions to use tobacco, our results imply that at least some smokers may have been deterred from using or switching to e-cigarettes due to the growing perception that e-cigarettes are equally harmful or more harmful than cigarettes.

2019: Perceived Comparative Harm of Cigarettes and Electronic Nicotine Delivery Systems

• Between 2017 and 2018, the percentage of US adults who perceived ENDS to be less harmful than cigarettes decreased, while there was an increase in the proportion of US adults who perceived ENDS to be more harmful or much more harmful.

2019: Misperceptions of Nicotine and Nicotine Reduction: The Importance of Public Education to Maximize the Benefits of a Nicotine Reduction Standard

• Recent population-level data highlight that 49%–80% of US adults incorrectly believe that nicotine is responsible for most of the cancer caused by smoking.
• Additionally, between 23% and 43% of young adults responded “don’t know” to items on nicotine perceptions and more than 50% of respondents, including past 30-day tobacco users, perceived nicotine gum and patch to be as harmful or more harmful than cigarettes to overall health and specifically, to causing cancer or heart attack.

2019: Impact of Brief Nicotine Messaging on Nicotine-Related Beliefs in a U.S. Sample

• Public education is an essential complement to the Food and Drug Administration’s efforts to move smokers away from combusted tobacco products and prevent non-users from trying nicotine and tobacco products.
• Following exposure, nicotine education participants reported fewer false beliefs about nicotine, nicotine replacement therapies, e-cigarettes, and reduced nicotine cigarettes compared with the control conditions.
• Nicotine messaging doubled the probability of a correct response (false, 78.3% vs 36.8%) to nicotine is a cause of cancer and dramatically reduced the probability of responding don’t know to this item (5.3% vs 26.0%).

2019: Misperceptions of Nicotine and Nicotine Reduction: The Importance of Public Education to Maximize the Benefits of a Nicotine Reduction Standard

• Given these common misperceptions about nicotine, a low nicotine product standard has potential to further confuse consumers about tobacco product risks in the absence of public education efforts.

2019: Reducing Nicotine Without Misleading the Public: Descriptions of Cigarette Nicotine Level and Accuracy of Perceptions About Nicotine Content, Addictiveness, and Risk

• Stating that 95% of nicotine would be removed more accurately conveyed the nicotine content and addictiveness of VLNC cigarettes. However, descriptions that better conveyed nicotine content and addictiveness misled people about cancer risk.

2018: Monitoring harm perceptions of smokeless tobacco products among U.S. adults: Health Information National Trends Survey 2012, 2014, 2015

• When asked whether smokeless tobacco products are less harmful than cigarettes, the majority of respondents across cycles said "no."
• PubPeerComment: Brad Rodu
  • The authors are from the U.S. FDA and National Cancer Institute.
  • The article failed to specify that the correct answer is: “Yes, smokeless tobacco products are less harmful than cigarettes.” In fact, it focused almost entirely on the majority of participants who inaccurately answered “No” or “Don’t Know,” which reflects misperception fostered by an effective “quarantine” of truthful risk information by federal agencies.

2017: Changing Perceptions of Harm of E-Cigarettes Among U.S. Adults, 2012-2015

• The findings of the current study indicate that, over time, U.S. adults, irrespective of smoking history, increasingly believe that e-cigarettes could be as harmful as combustible cigarettes
• Higher risk perceptions of e-cigarettes could deter current smokers from using e-cigarettes as a cessation aid of smoking combustible cigarettes and preventing a potential public health benefit.
• The finding that the higher percentages of adults, including current smokers, misperceived e-cigarettes to be equally or more harmful than cigarettes between 2012 and 2015 may be stemming from misinformed media stories

2017: Nicotine and E-cigarette Beliefs and Policy Support among US Smokers and Nonsmokers

• Whereas perception of harm associated with e-cigarettes was significantly lower for smokers than for nonsmokers, most respondents (80%), regardless of current smoking status, believed that nicotine is the primary disease-causing agent in tobacco products (nicotine harm perception).
• In multivariable analyses, believing that e-cigarettes were more harmful was associated with greater support for bans on indoor e-cigarette use, use in cars with children present, and a ban on e-cigarette sales to minors. As beliefs about e-cigarette harm increased, there was less support for a differentiated tax structure for e-cigarettes relative to combustible cigarettes.

2017: Opinion: America needs a candid smoking control champion

• Unfortunately, misinformation about nicotine abounds. The majority of Americans wrongly believe that e-cigarettes are at least as harmful as cigarettes.
• But current and future smokers, who are the ones in immediate peril, must also be able to make decisions based on truthful information about how new smokeless products differ in their relative harms from smoked tobacco.
• A purist stance misleads the public into thinking that all tobacco products are equally harmful.

2017: Article: Guest Post: Where Is FDA Going with Nicotine and Tobacco?

• The FDA faces many challenges to realize this future. But perhaps the greatest obstacle, based on FDA’s own data, is that upwards of 80% of smokers believe that nicotine itself is the primary ingredient that causes cancer. We hope that FDA uses its bully pulpit and other communication channels to correct the record; its bold plan will be even harder to execute if they do not.

2016: U.S. adults' addiction and harm beliefs about nicotine and low nicotine cigarettes

• Overall, we found that many people, particularly the demographic subgroups identified here, held incorrect beliefs about nicotine and potentially inaccurate beliefs about LNCs.
• Incorrectly believing that nicotine causes cancer could discourage smokers from switching to safer nicotine-containing alternatives, and could lead nonsmokers to experiment with low nicotine tobacco products, believing that cancer risk would be reduced.

2016: What the Public Knows and Believes About Nicotine: Insights from Recent Quantitative and Qualitative Evidence

• CTP Nicotine Qualitative Study Analysis - HINTS - PATH Wave 1

2015: Deficiencies in public understanding about tobacco harm reduction: results from a United States national survey

• The discrepancy between current evidence and public perceptions of relative risk of various tobacco/nicotine products was marked; for most tobacco types, a large proportion of the population held inaccurate harm reduction beliefs.
• Given the potential benefits of tobacco risk reduction strategies, public health education efforts to increase understanding of basic harm reduction principles are needed to address these misperceptions.

2011: Providing accurate safety information may increase a smoker's willingness to use nicotine replacement therapy as part of a quit attempt

• 93% of smokers did not know that smoking while wearing the nicotine patch does not cause heart attacks; 76% that nicotine gum/lozenge are not as addictive as cigarettes; and 69% that NRT products are not as dangerous as cigarettes. Over half of the smokers with misperceptions reported that they would be more likely to use NRT (nicotine replacement therapy) to help them quit smoking if they were exposed to information correcting their concerns

2008: Perceived safety and efficacy of nicotine replacement therapies among US smokers and ex-smokers: relationship with use and compliance

• Two-thirds (66%) of respondents either agreed that 'Stop-smoking products with nicotine are just as harmful as cigarettes' or were unsure whether the statement was true.
• The findings suggest that many smokers are misinformed about the health risks of NRT and that these misperceptions impede not only the adoption of NRT but also compliance during treatment. Misperception of NRT safety is one barrier to effective use of NRT and probably reduces success in quitting.
• Commentary - IMPROVING NRT LABELING AND CORRECTING PUBLIC MISPERCEPTIONS

2004: Stop-smoking medications: who uses them, who misuses them, and who is misinformed about them?

• The data reveal that most smokers are misinformed about the health risks of nicotine and the safety/efficacy of nicotine medications. Approximately half incorrectly reported that the reduction in nicotine in cigarettes has made cigarettes less dangerous to health and only one-third correctly reported that nicotine patches were less likely to cause a heart attack than smoking cigarettes. Smokers who were more knowledgeable about the health risks of nicotine and the safety and efficacy of nicotine medications were more likely to report past use of nicotine medications. Misperceptions about the health risks of nicotine and the safety/efficacy of nicotine medications may discourage some smokers from considering the use of these medications to help them stop smoking.
• PDF Version

Health Care

2023: Doctors' Survey: USA results

• Physicians Have Misperceptions About Nicotine
• Participants were asked: “To what extent do you agree that nicotine by itself directly causes each of the smoking-related conditions below. The results include responses from “moderately agree” to “completely agree.”
  • 75% - Nicotine causes atherosclerosis
  • 72% - Nicotine causes birth defects
  • 69% - Nicotine causes head/neck gastric cancers
  • 69% - Nicotine causes bladder cancer
  • 67% - Nicotine causes lung cancer
  • 66% - Nicotine causes COPD

2023: College health providers' knowledge and confidence in addressing students' vaping: Evidence from a pilot study in New York State

• More than half (64%; n = 32) of providers indicated they do not know what type of product students on their campus are vaping most often (nicotine or cannabis.
• In fact, when further asked about the harms and messaging surrounding e-cigarettes, most providers (68%; n = 32) indicated that e-cigarettes are “just as harmful as cigarettes and should not be recommended as a safer alternative for smokers;”
• In a separate question, when presented with two options about the messaging of e-cigarettes, college health providers largely favored (85%; n = 40) messaging that e-cigarettes are not a safe alternative to cigarettes.

2022: Communication Between US Physicians and Patients Regarding Electronic Cigarette Use

• 60% of physician respondents incorrectly believe all tobacco products were equally harmful
• It is critical to address physician nicotine misperceptions and to correct misperceptions regarding the relative harm of various tobacco products as more modified-risk tobacco products may be introduced through an FDA authorization process.
• Twitter thread by Cristine D. Delnevo, PhD, MPH about the study

2021: Persistent Misperceptions about Nicotine among US Physicians: Results from a Randomized Survey Experiment

• Question wording is important when measuring physicians’ beliefs about nicotine; however, even after accounting for question version, misperceptions about the direct health effects of nicotine were common and varied by sex and specialty.

2021: Nicotine-related misperceptions among faculty and students at a Midwestern dental school

• The response rate for faculty was 55.1% and that for students was 37.5%. The majority of faculty and students “agreed” or “strongly agreed” that nicotine causes cancer, birth defects, cardiovascular disease, oral inflammation, and Chronic Obstructive Pulmonary Disease.
• Dental school faculty and students linked the risks of smoking tobacco to nicotine. Based on the results of this study, we feel our institution's curriculum should consider including information specific to nicotine in addition to tobacco in general.

2021: Otolaryngology Resident Education and Perceptions of e-cigarettes

• The most common resource of e-cigarette information overall was social media (78.46%).
• Within academia, the most common resources of e-cigarette education were patient interactions (63.16%) and colleagues (54.74%).

2020: Nicotine Risk Misperception Among US Physicians

• Overall, the majority of physicians “strongly agreed” that nicotine directly contributes to the development of cardiovascular disease (83.2%), COPD (80.9%), and cancer (80.5%). Comparatively fewer “strongly agreed” that nicotine directly contributes to the development of birth defects (32.9%) and 30.2% did not answer this question—a potential indicator of “do not know.”
• While it is possible that some physicians may have misunderstood the question (e.g., considered harm caused by tobacco, rather than nicotine), results are consistent with other studies finding notable nicotine misperceptions.
• PDF Version
• Rutgers Article: Rutgers-Led National Survey Uncovers Doctors' Misconceptions About Nicotine Risks
• Rutgers Article: Researchers say physicians need to understand accurate nicotine risks better to assist patients addicted to the most harmful tobacco products
• Filter Article: Majority of Surveyed Doctors Misattribute Tobacco Harms to Nicotine

2015: Healthcare Providers’ Beliefs and Attitudes About Electronic Cigarettes and Preventive Counseling for Adolescent Patients

• The most frequently cited sources of information about e-cigarettes were patients, news stories, and advertisements, rather than professional sources.

2007: Nurses' knowledge about the risk of light cigarettes and other tobacco "harm reduction" strategies

• Nurses had misperceptions about nicotine replacement: 60% believed that nicotine causes cancer, 72% believed that nicotine patches could cause heart attacks, and 40% and 15% believed that a prescription is needed for the nicotine patch or gum, respectively.
• Nurse misinformation could lead to inaccurate recommendations and failure to capitalize on the teachable moment provided by the medical encounter.

Unknown Nation(s)

Consumer

2022: Discussions and Misinformation About Electronic Nicotine Delivery Systems and COVID-19: Qualitative Analysis of Twitter Content

• Misinformation and conspiracy theories were present throughout all coding categories.

2021: Effect of brief nicotine corrective messaging on nicotine beliefs in persons who use opioids

• Brief nicotine messaging increased the probability of a correct response to "Nicotine is a cause of cancer" (false, 63% vs. 36%) and reduced the probability of a don't know response (9% vs. 17%) compared to the no message control condition.

Nicotine Misperceptions and VLNC (Very Low Nicotine Cigarettes)

Consumer

2019: Reducing Nicotine Without Misleading the Public: Descriptions of Cigarette Nicotine Level and Accuracy of Perceptions About Nicotine Content, Addictiveness, and Risk

• The public incorrectly believes very low nicotine content (VLNC) cigarettes are less carcinogenic than current cigarettes, a belief associated with lower motivation to quit under a VLNC standard.

2019: Public misperception that very low nicotine cigarettes are less carcinogenic

• Many smokers had the misperception that smoking VLNC cigarettes is less likely to cause cancer, and some stated that they would be less likely to quit. A VLNC standard may be more effective if accompanied by a communication campaign that emphasizes the continued dangers of smoking VLNC cigarettes due to the many toxic chemicals in smoke.

2017: U.S. adults' addiction and harm beliefs about nicotine and low nicotine cigarettes

• About three quarters of people either were unsure of the relationship between nicotine and cancer or incorrectly believed that nicotine causes cancer. Incorrectly believing that nicotine causes cancer could discourage smokers from switching to safer nicotine-containing alternatives, and could lead nonsmokers to experiment with low nicotine tobacco products, believing that cancer risk would be reduced. Findings underscore the need to educate the public on the health effects of nicotine and LNCs...

2017: Low Nicotine Content Descriptors Reduce Perceived Health Risks and Positive Cigarette Ratings in Participants Using Very Low Nicotine Content Cigarettes

• Subjects rated the "very low" nicotine cigarette as less harmful to their health overall compared to the "average" nicotine cigarette; this effect held true for specific smoking-related diseases.

Science - Methodological Flaws Can Lead to Misinformation About Nicotine

2023: Physical and chemical characterizations of a reference e-cigarette used in animal testing

• The paper calibrates and tests this equipment, showing the potential problems of exposing these biological systems when the aerosol is generated by a high powered device with sub-ohm coils and an inapprotriately low airflow. This grossly deviates from consumer usage of these divices and is also  the perfect storm for generating aerosols under overheating conditions and high toxin’s load.  
• Many cell/rodent studies report deleterious biological effects from the exposure to e-cigarette aerosol, thus contributing to the vaping harm narrative, but often the aerosols are unrealistic, overheated and toxic. A second paper is forecoming in which we will revise 19 studies with this problem, there are bound to be much more.
• Sébastien Soulet, Léa Constant & Vanille Quinty Scientific Reports volume 13, Article number: 16624 (2023)

Science Hygiene - The Call To Correct Misinformation About Nicotine

Academic Community

• This section outgrew this page and is now located on the Nicotine - Retracted Studies, Papers, and Articles page.

2021: Referring to: Erosive potential of commonly available vapes: a cause for concern?

• 2022: Vaping misrepresentations
  • We were disappointed to see several basic errors and misrepresentations.
  • E-cigarettes do not contain tobacco and should not be categorised as such
  • The authors incorrectly claim that nicotine causes a 'high risk of oral and whole-body health complications'.
  • The authors claim that e-cigarettes are associated with cancer. The supporting reference does not make this claim...
  • The authors state that 'diacetyl is found in most flavoured vapes'. Again, the supporting reference is inappropriate...
  • The authors grossly misrepresent the public health guidance on e-cigarette use as a smoking cessation device.

2021: Video: Are we risking the erosion of trust in Tobacco Control?

• Prof Mike Cummings presenting at E-Cigarette Summit 2021
• Successful public health campaigns rely on establishing and maintaining the public’s trust in the recommendations that are given. This presentation highlights concerns that I have about the erosion of trust in tobacco control that appears to be happening because previously trusted public health officials are staking out policy positions that distort the truth about lower risk alternative nicotine products.

2019: Referring to: 2019: Prevalence of vaping and smoking among adolescents in Canada, England, and the United States: repeat national cross sectional surveys

• 2020: Also referring to: Update 2020
• 2020: Canada takes a wrong turn after a flawed paper induces moral panic about youth vaping and smoking
• 2019 and 2020: PubPeer Comments
• >>>NOTE TO SKIP<<< Continue here

2020: Bad Data and Bad Conclusions Will Lead to Bad Policy – Implausible Claims that Vaping Increases COVID-19 Risk for Youth and Young Adults

• In this brief peer review, we argue that the data reported by Gaiha et al (doi:10.1016/j.jadohealth.2020.07.002) regarding associations between vaping and COVID-19 testing are so suspect that any conclusions drawn from it cannot be relied upon. We discuss six main areas of concern and conclude that the paper should be retracted.
• More comments addressing concerns on PubPeer
  • 7 comments at the time of this Wiki entry
• Letter to the journal editor: E-Cigarette Use and COVID-19: Questioning Data Reliability
  • It is not biologically plausible that e-cigarette trial or experimentation would cause effects that result in stronger predisposition to COVID-19 than current/regular use. Therefore, no causal link between e-cigarette use and COVID-19 can be implied.
• Letter to the journal editor: Gaiha et al. Disregarded Conventional Publishing Standards
  • The article deviated from standard reporting practices in several ways.
  • We asked the authors to provide actual numbers. They declined.
  • The authors’ claims have already prompted national policy recommendations by members of Congress.
• Letter to the journal editor: Gaiha et al. Response
  • However, the association reported by Gaiha et al. is not necessarily indicative of a causal relationship between e-cigarette use and contracting COVID-19.
• Letter to the journal editor: In Response to “Association Between Youth Smoking, Electronic Cigarette Use, and COVID-19”
  • We believe that this article has multiple scientific shortcomings leading to flawed data analysis that render the results unreliable. Of particular concern is the fact that this flawed study is being used as ‘evidence’ by Congressman Krishnamoorthi to campaign for a ban on the use of all e-cigarettes in the U.S.
• The Authors Respond
  • We are in complete agreement with others' assertions that our study does not imply causality.
• Article: Experts Question Study Claiming E-Cigarettes Are a COVID-19 Risk Factor
  • A number of experts responded swiftly to the study's abnormal findings that lacked a credible causal theory.

2020: Vaping Nicotine Is Far Less Harmful Than Smoking Tobacco

• Comments referring to: "The evolving landscape of e-cigarettes: a systematic review of recent evidence".
• In a previous issue of CHEST (May 2020), Bozier et al1 reviewed the recent research on the potential health effects of e-cigarettes. We would like to comment on several of the claims made in the article.

2020: Vaping risk compared to smoking: challenging a false and dangerous claim

• Comments referring to: "The Evidence of Electronic Cigarette Risks Is Catching Up With Public Perception"
  • The overall claim made by Professor Glantz is that the public is right to regard vaping as equivalent in risk to smoking, and science is catching up. This is an unambiguously false and dangerous claim with material risks for health: it may encourage vapers to revert to smoking or smokers not to switch, and policymakers to adopts unduly restrictive measures on e-cigarettes that amount to regulatory protection for the cigarette trade.
• A more in-depth commentary: Vaping risk compared to smoking: challenging a false and dangerous claim by Professor Stanton Glantz

2020: PubPeer Comments RE: Myocardial Infarction

• Comments referring to: Electronic Cigarette Use and Myocardial Infarction Among Adults in the US Population Assessment of Tobacco and Health.
• NOTE: This paper has been RETRACTED by the journal
• Dr. Brad Rodu: "The main findings from this study are false and invalid. Their analysis was an indefensible breach of any reasonable standard for research on association or causation."
• Additional comments follow Dr. Rodu's and document the difficulties encountered by Public Health experts to get the above-mentioned misleading study retracted.
• Retraction Notice: Retraction to: Electronic Cigarette Use and Myocardial Infarction Among Adults in the US Population Assessment of Tobacco and Health
  • Given these issues, the editors are concerned that the study conclusion is unreliable. The editors hereby retract the article from publication in Journal of the American Heart Association.
• From Retraction Watch: Journal retracts hotly contested paper on vaping and heart attacks
• Article: Here Comes Trouble: An Anti-Tobacco Hero’s Complicated Legacy

Media

2022: Toward an ontology of tobacco, nicotine and vaping products

• See: EVALI (and maybe other things)

Regulators, Government Agencies, and Policy Makers

2022: An Independent Review of FDA’s Tobacco Regulations Would Be Welcome as Agency Bows Down to Political Pressure

• Lawmakers who continue to flout misleading statements...

Multiple years - Ongoing even after being debunked: Popcorn Lung

• For more information on Popcorn Lung see: Science Hygiene - The Call To Correct Misinformation About Nicotine>> Non-profits or Their Funders
• 2020: Nora Volkow, MN (NIDA, NIH) - Collision of the COVID-19 and Addiction Epidemics
  • The highly publicized lung illnesses from vaping, including “popcorn lung” and e-cigarette or vaping product use–associated lung injury, alert us to the potential for lung injury from vaping, which is on the rise especially in young persons.
  • Article: Filter - Anti-Vaping Zealots Find Opportunity in the Pandemic
• 2015: New Study Finds that Average Diacetyl Exposure from Vaping is 750 Times Lower than from Smoking
• 2015: Medical journal MISPRESENTS a case of hypersensitivity pneumonitis as popcorn lung disease caused by e-cigarette
• Cancer Research UK: Does vaping cause popcorn lung?
  • E-cigarettes don’t cause the lung condition known as popcorn lung
  • There have been no confirmed cases of popcorn lung reported in people who use e-cigarettes
  • E-cigarettes are one of the tools that can help people who smoke to stop
• 2022: What are people’s views about the risks of vaping? Findings from conversations with the public.
  • What might be causing an increase in inaccurate views of the harms of vaping compared to smoking?
  • Misinformation about vaping (for example, that it can cause popcorn lung)

2020: Gaze Upon the Worst Anti-Vaping Poster Ever and Despair

• 'But when you're dealing with propaganda, it's best not to get too lost in the weeds... When targets of such communications realize they're being lied to, they tend to tune out all the information from official sources because they know it's not really unbiased, scientific, or seeking the truth."

2019 and Beyond: The CDC, the FDA, and others: EVALI

• Article: The CDC’s EVALI screwup
  • Making a mistake is one thing. Failing to correct it is worse.
  • But there is no evidence–none at all— that anyone got sick with EVALI from using e-cigarettes.
• Twitter thread by Mike Pesko about the letter to the CDC requesting them to change the name of EVALI, and the CDC's refusal to do so. This letter was signed by 75 international tobacco control / public health experts.
• Paper: Vitamin E Acetate is not Soluble in Nicotine E-liquids
  • Vitamin E acetate is not soluble in formulations of nicotine e-liquids and if mixed into a nicotine e-liquid will form a visibly distinct layer. Therefore, it is unlikely that nicotine-only e-cig users will be exposed to vitamin E acetate.
• Paper: The outbreak of lung injuries often known as "EVALI" was nothing to do with nicotine vaping
  • An examination of the evidence shows that EVALI cannot have been caused by nicotine vaping. The characteristics of the lung injury outbreak are consistent with localised supply chain contamination. The contaminant has been identified and is known to be Vitamin E Acetate. This had been used as a thickener or cutting agent in illicit Tetrahydrocannabinol (THC) cannabis vape pens. This agent cannot be mixed with nicotine vaping liquids and would serve no useful purpose if it could be.
• Article: E-Cigarettes Increasingly Blamed for Lung Illnesses, as Evidence Points Elsewhere
  • CDC identified THC vapes with vitamin E acetate as culprit, but 66% of adults blame e-cigarettes for vaping deaths
• Tweets by Scott Gottlieb, MD
  • An e-cigarette is an FDA regulated electronic nicotine delivery system (ENDS). It delivers nicotine. What CDC seems to be trying to refer to here are illegal vapes or “dabs” that contain THC. We develop precise regulatory nomenclature for a reason. It helps differentiate products
  • CDC should reconsider the name it ascribed to these illnesses (EVALI) now that it seems to be definitively linked to THC vapes and dabs. By not speaking with precision it could leave a false impression as to the clear causal relationship between the tragic illnesses and THC vapes
  • The public health risk is that kids using these illegal and dangerous THC products may not know that the CDC warnings relate to the THC products they’re using; since the CDC is not using a precise nomenclature to more clearly describe the THC vapes and dabs
• Tweet by Scott Gottlieb MD
  • My point is simply if you know a THC product hurt someone, don’t call it an e-cigarette, call it a THC vape or THC vaping product. Nomenclature matters in helping consumers properly identify which products are causing which kinds of risks. That’s why we develop naming systems.

2018 and Beyond: Youth Vaping Epidemic: US Surgeon General, FDA, CDC, etc.

• Slide 22/83 - FDA research findings on using the word "epidemic" - shows they were aware of the unintended consequence of deterring adults from using e-cigs to quit smoking. They went ahead with the campaign.
• US Surgeon General issues advisory on youth vaping epidemic.
  • Dec 2018: NPR story about SG advisory and the CDC issues information about the SG advisory.
• Dec 2019: FDA’s So-Called Laser Targeted Advertising is Hypocritical, and Deadly.
  • The FDA found that its campaign would convince adult smokers that e-cigarettes were equally or more harmful than cigarettes and suppress quitting, and still the agency proceeded with its dangerous misinformation program.
  • How did the FDA campaign, which has been supported by other government and medical organizations, work out? As the chart shows, pre-campaign, nearly 40% of Americans believed that e-cigarettes were safer than cigarettes in 2012. By 2018, that number had cratered to a mere 17%.

2017: Objectivity and Evidence in the 2016 Surgeon General’s Report on E-Cigarettes

• A more careful read, however, reveals important areas where the report falls short.
• One of the more surprising shortcomings of the 2016 SGR is located early in the document when the reader is informed that recent studies were included if they conformed to conclusions that had already been reached...the selection of evidence to align with preset conclusions represents a type of bias known as “confirmation bias.”
• Other concerns not completely covered or covered in a biased way: age of purchase laws, studies on cognition, prenatal exposure...
• Incomplete or biased messaging on the effects of these and other nicotine products must be avoided at all costs in order to support the public in making personal choices that are informed by the best available evidence.

Non-profits or Their Funders

2022: The Half-Truth Initiative: How an Anti-Smoking Group Lost Its Way

• “We’re not talking misinformation. We’re talking disinformation. This is willful misrepresentation of facts. It’s mind-blowing.”

2021: Video: Are we risking the erosion of trust in Tobacco Control?

• Prof Mike Cummings presenting at E-Cigarette Summit 2021
• Successful public health campaigns rely on establishing and maintaining the public’s trust in the recommendations that are given. This presentation highlights concerns that I have about the erosion of trust in tobacco control that appears to be happening because previously trusted public health officials are staking out policy positions that distort the truth about lower risk alternative nicotine products.

2021: Truth Initiative's Depression Sticks Campaign

• 2021: Video: Depression causes vaping!
  • In this talk Professor Notley will discuss the latest evidence exploring associations between nicotine use and common mental health conditions, including depression.
  • Interpretive assumptions will be drawn out, including inappropriate claims of causal relationships between vaping and depression.
• 2021: Video (Consumer) The Truth about #DepressionSticks
  • Depression is nothing to laugh about or stigmatize. @TruthInitiative has created a multi-million dollar ad campaign that does both. @imaracingmom opens up about her struggle with depression and her pain magnified by the #DepressionStick misinformation campaign. They make light of youth depression and shame people for trying to minimize their suffering by any means necessary. It's time we told them you will not shame me. You will not reduce my suffering to a hashtag and you will not lie to me any more.

Multiple years - Ongoing even after being debunked: Popcorn Lung

• See also: Science Hygiene - The Call To Correct Misinformation About Nicotine >>> Regulators, Government Agencies, and Policy Makers
• Scaremongering shared by many health organizations. A few Examples:
  • American Lung Association, Tobacco Free Colorado, Say San Diego
  • Several NGOs sued the FDA in 2018 - they used misleading information on Popcorn lung as part of their evidence (#45 page 21/70) as to why they felt the submission date for Pre-Market Tobacco Applications (PMTA) needed to be changed.
• 2015: New Study Finds that Average Diacetyl Exposure from Vaping is 750 Times Lower than from Smoking
• 2015: Medical journal MISPRESENTS a case of hypersensitivity pneumonitis as popcorn lung disease caused by e-cigarette
• Cancer Research UK: Does vaping cause popcorn lung?
  • E-cigarettes don’t cause the lung condition known as popcorn lung
  • There have been no confirmed cases of popcorn lung reported in people who use e-cigarettes
  • E-cigarettes are one of the tools that can help people who smoke to stop
• 2022: What are people’s views about the risks of vaping? Findings from conversations with the public.
  • What might be causing an increase in inaccurate views of the harms of vaping compared to smoking?
  • Misinformation about vaping (for example, that it can cause popcorn lung)

Learn more about misinformation - not nicotine related

2021: FLOATER: A Tool-Kit for Evaluating Claims

• A Life Preserver for Staying Afloat in a Sea of Misinformation

Changing Minds & Bias - Why is it so hard to correct misinformation with facts?

2018: The spread of true and false news online

• 2022: A thought-provoking MUST READ follow up to this story: Fake News about our Fake News Study Spread Faster than its Truth… Just as We Predicted.

Reasons For Hiding The Truth

Suggestions to add to this page

2023: Commentary on Wackowski et al.: Opportunities and Considerations for Addressing Misperceptions About the Relative Risks of Tobacco Products among Adult Smokers

• Article: Many adults who smoke cigarettes wrongly think that vaping is worse for them, say Hollings researcher and FDA Center for Tobacco Products director
• 2023: Perceptions about levels of harmful chemicals in e-cigarettes relative to cigarettes, and associations with relative e-cigarette harm perceptions, e-cigarette use and interest

2022: A tale of flawed e-cigarette research undetected by defective peer review process

• Anti-vaping narrative driven by low quality science goes undetected by editorial quality checks

2022: UK report underscores potential of e-cigarettes to reduce smoking harms

• "The Nicotine Vaping in England report suggests that health risks of vaping are often overstated, resulting in inaccurate risk perceptions that could deter people who use the most harmful product (cigarettes) from switching to less harmful product (e-cigarettes). According to representative surveys of young people (11–18 years) and adults (≥18 years) in England in 2021, 55°3% of young people and 65·9% of adult smokers and vapers in England mistakenly think that vaping is as harmful or more harmful than smoking.2 Such inaccurate perceptions have probably been fuelled by misrepresentative news coverage of e-cigarette harms, such as that of the US outbreak of vaping-associated lung injury in 2019, which was caused by inhaling vitamin E acetate, an additive in cannabis vaping devices, rather than standard nicotine e-cigarettes.4 In an effort to uphold the precautionary principle, the health community may have inadvertently aided the promotion of misinformation.5"

2022: Article: Vape wars: The fierce debate over the banning (and unbanning) of Juul e-cigarettes

• For Non-Subscribers to the Boston Globe, this is viewable "incognito"

2022: Electronic nicotine delivery systems: prevalence and perception of risk/harm in individuals with mental illness

• Singapore

2022: E-cigarette use, opinion about harmfulness and addiction among university students in Bratislava, Slovakia

• PDF Version

2019: Statement on the dangers posed by e-cigarettes

• Drug Science UK

2017: RSPH - Targeting the supply and sale of e-cigarettes to smokers

• Among smokers who have never vaped, only 1 in 8 (12%) correctly believe e-cigarettes are a lot less harmful than cigarettes.

2017: Use of e-cigarettes among adults in Great Britain 2017

• In 2017 under a third of smokers understood that NRT was much less harmful than smoking. Among smokers, perceptions are also getting worse with only 20% accurately believing in 2017 that e-cigs are less harmful than smoking compared with 31% in 2015.

2016: Bad science, accountability and courage – speech by AG Tom Miller