18B.11 Public perceptions of e-cigarettes

Last updated: January 2019

Suggested citation: Greenhalgh, EM, & Scollo, MM. InDepth 18B: Electronic cigarettes (e-cigarettes). In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2017. Available from: http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18b-e-cigarettes

Current and former smokers—who comprise the vast majority of e-cigarette users—generally perceive e-cigarettes as less harmful than tobacco cigarettes, and as potentially helpful in their attempts at smoking reduction or cessation.1-10 (Refer Section 18B.7 for findings of research on efficacy for smoking cessation). Survey research in NSW found that the most common reasons for using e-cigarettes among smokers over 30 was “to help me quit” and to “cut down” smoking; for younger adults it was “because they are not as bad for your health as cigarettes”.11  An analysis of Australian and UK data from the 2013 International Tobacco Control Four-Country project found that, consistent with the country’s less stringent regulations, smokers and recent ex-smokers in the UK were more likely to perceive e-cigarettes as less harmful than cigarettes, compared to those in Australia.12 Continued use of e-cigarettes among smokers appears to depend on whether the products live up to expectations regarding short-term health improvements and ability to mimic smoking behaviours.13   

Among the general public, research in 2013–14 in the US found that fewer than half (40.7%) of adults believed that e-cigarettes were less harmful than cigarettes, although they were most likely to be seen as less harmful compared with other products (such as hookah and cigars).14 Many also report having rules prohibiting e-cigarette use inside homes and vehicles.15 Another study in the US found that more positive affect towards e-cigarettes was associated with lower perceived risks, which in turn was associated with higher odds of being a current e-cigarette user.16 In a sample of young Australian adults, the majority believed e-cigarettes have some level of harm (72%), and just over half believed them to be addictive (57%); however many did not know whether e-cigarettes are harmful (20%) or addictive (34%). Forty-two per cent believed e-cigarettes are effective cessation aids. Smokers and users tended to be more positive about the products.17

Among adolescents, e-cigarettes are generally perceived as less harmful than conventional cigarettes,18 and also as less addictive.19, 20  Such perceptions of lesser harm appear to predict later use of e-cigarettes.21 One US study found that compared with never-users, youth who had ever or currently used e-cigarettes believed them to be not at all harmful or addictive, and were more likely to report flavoured products were less harmful than non-flavoured.19 Qualitative research in the UK found that adolescents perceive the products are ‘fun’, and find the diverse range of flavours particularly appealing.22 The wide range of sweet flavours is one of the most commonly cited reasons for experimentation among children, along with curiosity.23-26 A review found that young people tend to highlight the trendiness of e-cigarettes as a perceived benefit, and perceive fewer health benefits than adults.13

Despite the general beliefs about potential for reduced health risk noted above, perceptions of harm appear to be increasing. Research in the EU found that between 2012 and 2014, the perception that e-cigarettes are harmful increased from 27.1% to 51.6%, although there were major differences between member states.27 Studies in the UK28 and the US29-31 have similarly found that the proportion of people who perceive vaping as less harmful than smoking has decreased over time. One found that the proportion of people who did not think vaping could help people quit, that thought vaping was addictive, and that thought vape was comparable to secondhand smoke increased between 2015 and 2016.29

Surveys of health professionals have also found uncertainty regarding the safety and efficacy of e-cigarettes. A study of Australian pharmacy staff found many reported a lack of confidence in the safety of e-cigarettes that contained nicotine, although most regarded e-cigarettes as less harmful than tobacco cigarettes.32 A survey of Australian cardiothoracic surgeons found that although e-cigarettes were perceived as unlikely to be safe (although less harmful than cigarettes), they may have a role as a perioperative smoking cessation aid.33 Results from the ITC Four Country Smoking and Vaping Survey showed that few health professionals in Australia, Canada, England, and the US are discussing with or recommending vaping products to patients.34 People generally report greater trust in medical professionals and public health organisations for providing accurate information on e-cigarettes public health sources than those with commercial interests; therefore health professionals may be able to effectively counter e-cigarette promotion and improve public knowledge.35

Relevant news and research

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1. Adkison S, O'Connor R, Bansal-Travers M, Hyland A, Borland R, et al. Electronic nicotine delivery systems: International tobacco control four-country survey. American Journal of Preventive Medicine, 2013; 44(3):207–15. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3627474/pdf/nihms437547.pdf

2. Bauhoff S, Montero A, and Scharf D. Perceptions of e-cigarettes: A comparison of adult smokers and non-smokers in a Mechanical Turk sample. American Journal of Drug and Alcohol Abuse, 2016:1–13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27712126

3. Tomashefski A. The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review. Journal of the American Association of Nurse Practitioners, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26997487

4. Czoli CD, Fong GT, Mays D, and Hammond D. How do consumers perceive differences in risk across nicotine products? A review of relative risk perceptions across smokeless tobacco, e-cigarettes, nicotine replacement therapy and combustible cigarettes. Tobacco Control, 2017; 26(e1):e49–e58. Available from: http://tobaccocontrol.bmj.com/content/tobaccocontrol/26/e1/e49.full.pdf

5. Pepper JK, Emery SL, Ribisl KM, Rini CM, and Brewer NT. How risky is it to use e-cigarettes? Smokers' beliefs about their health risks from using novel and traditional tobacco products. Journal of Behavioral Medicine, 2015; 38(2):318–26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25348584

6. Xu Y, Guo Y, Liu K, Liu Z, and Wang X. E-cigarette awareness, use, and harm perception among adults: A meta-analysis of observational studies. PLoS ONE, 2016; 11(11):e0165938. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27861501

7. Couraud S, Cortot AB, Pivot XB, Touboul C, Lhomel C, et al. Beliefs and behavior regarding e-cigarettes in a large cross-sectional survey. Preventive Medicine Reports, 2018; 10:332–6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29868388

8. Goldberg RL, Dankiewicz C, and Cataldo JK. Older smokers' beliefs about e-cigarettes and intent to quit conventional cigarettes. Journal of Gerontological Nursing, 2018; 44(12):17–24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30484844

9. Merry S and Bullen CR. E-cigarette use in New Zealand-a systematic review and narrative synthesis. New Zealand Medical Journal, 2018; 131(1470):37–50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29470471

10. Truman P, Glover M, and Fraser T. An online survey of New Zealand vapers. International Journal of Environmental Research and Public Health, 2018; 15(2). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29382129

11. Dunlop S, Lyons C, Dessaix A, and Currow D. How are tobacco smokers using e-cigarettes? Patterns of use, reasons for use and places of purchase in New South Wales. Medical Journal of Australia, 2016; 204(9):355. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27169972

12. Yong H, Borland R, Balmford J, Hitchman S, Cummings K, et al. Prevalence and correlates of the belief that electronic cigarettes are a lot less harmful than conventional cigarettes under the different regulatory environments of Australia and the United Kingdom. Nicotine & Tobacco Research, 2017; 19(2):258–63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27190403

13. Romijnders K, van Osch L, de Vries H, and Talhout R. Perceptions and reasons regarding e-cigarette use among users and non-users: A narrative literature review. International Journal of Environmental Research and Public Health, 2018; 15(6). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29882828

14. Fong GT, Elton-Marshall T, Driezen P, Kaufman AR, Cummings KM, et al. U.S. Adult perceptions of the harmfulness of tobacco products: Descriptive findings from the 2013-14 baseline wave 1 of the path study. Addictive Behaviors, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30502927

15. Gentzke AS, Homa DM, Kenemer JB, Gomez Y, and King BA. Rules to prohibit the use of electronic vapor products inside homes and personal vehicles among adults in the US, 2017. Preventive Medicine, 2018; 114:47–53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29857024

16. Popova L, Owusu D, Weaver SR, Kemp CB, Mertz CK, et al. Affect, risk perception, and the use of cigarettes and e-cigarettes: A population study of US adults. BMC Public Health, 2018; 18(1):395. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29566752

17. Jongenelis MI, Kameron C, Rudaizky D, Slevin T, and Pettigrew S. Perceptions of the harm, addictiveness, and smoking cessation effectiveness of e-cigarettes among Australian young adults. Addictive Behaviors, 2018; 90:217–21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30447513

18. East K, Brose LS, McNeill A, Cheeseman H, Arnott D, et al. Harm perceptions of electronic cigarettes and nicotine: A nationally representative cross-sectional survey of young people in Great Britain. Drug and Alcohol Dependence, 2018; 192:257–63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30300799

19. Cooper M, Harrell MB, Perez A, Delk J, and Perry CL. Flavorings and perceived harm and addictiveness of e-cigarettes among youth. Tobacco Regulatory Science, 2016; 2(3):278–89. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27722185

20. Cooper M, Loukas A, Harrell MB, and Perry CL. College students' perceptions of risk and addictiveness of e-cigarettes and cigarettes. Journal of American College Health, 2016:1–9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27805472

21. Parker MA, Villanti AC, Quisenberry AJ, Stanton CA, Doogan NJ, et al. Tobacco product harm perceptions and new use. Pediatrics, 2018. Available from: http://pediatrics.aappublications.org/content/pediatrics/142/6/e20181505.full.pdf

22. Hilton S, Weishaar H, Sweeting H, Trevisan F, and Katikireddi SV. E-cigarettes, a safer alternative for teenagers? A uk focus group study of teenagers' views. BMJ Open, 2016; 6(11):e013271. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27852721

23. Measham F, O’Brien K, and Turnbull G. “Skittles & red bull is my favourite flavour”: E-cigarettes, smoking, vaping and the changing landscape of nicotine consumption amongst British teenagers – implications for the normalisation debate. Drugs: Education, Prevention and Policy, 2016; 23(3):224–37. Available from: http://dx.doi.org/10.1080/09687637.2016.1178708

24. Kong G, Morean ME, Cavallo DA, Camenga DR, and Krishnan-Sarin S. Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine & Tobacco Research, 2015; 17(7):847–54. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25481917

25. Harrell MB, Weaver SR, Loukas A, Creamer M, Marti CN, et al. Flavored e-cigarette use: Characterizing youth, young adult, and adult users. Preventive Medicine Reports, 2017; 5:33–40. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27896041

26. Pepper JK, Ribisl KM, and Brewer NT. Adolescents' interest in trying flavoured e-cigarettes. Tobacco Control, 2016; 25(Suppl 2):ii62–ii6. Available from: http://tobaccocontrol.bmj.com/content/25/Suppl_2/ii62.abstract

27. Filippidis FT, Laverty AA, Gerovasili V, and Vardavas CI. Two-year trends and predictors of e-cigarette use in 27 European union member states. Tobacco Control, 2017; 26(1):98–104. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27220621

28. McNeill A, Brose LS, Calder R, Bauld L, and Robson D. Evidence review of e-cigarettes and heated tobacco products 2018: A report commissioned by Public Health England. Public Health England, London: Public Health England, 2018. Available from: https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review.

29. Mincer J. U.S. E-cigarette use stalls as health concerns grow: Reuters/ipsos poll. Reuters,  2016. Available from: http://uk.reuters.com/article/us-usa-ecigarettes-poll-idUKKCN0YF0DE

30. Majeed BA, Weaver SR, Gregory KR, Whitney CF, Slovic P, et al. Changing perceptions of harm of e-cigarettes among US adults, 2012-2015. American Journal of Preventive Medicine, 2017; 52(3):331–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28341303

31. Huerta TR, Walker DM, Mullen D, Johnson TJ, and Ford EW. Trends in e-cigarette awareness and perceived harmfulness in the US. American Journal of Preventive Medicine, 2016. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27890516

32. Erku DA, Gartner CE, Do JT, Morphett K, and Steadman KJ. Electronic nicotine delivery systems (e-cigarettes) as a smoking cessation aid: A survey among pharmacy staff in Queensland, Australia. Addictive Behaviors, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30224155

33. Luxton NA, Shih P, and Rahman MA. Electronic cigarettes and smoking cessation in the perioperative period of cardiothoracic surgery: Views of Australian clinicians. International Journal of Environmental Research and Public Health, 2018; 15(11). Available from: https://www.ncbi.nlm.nih.gov/pubmed/30405035

34. Gravely S, Thrasher JF, Cummings KM, Ouimet J, McNeill A, et al. Discussions between health professionals and smokers about nicotine vaping products: Results from the 2016 ITC four country smoking and vaping survey. Addiction, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30548374

35. Owusu D, Weaver SR, Yang B, Ashley DL, and Popova L. Trends in trust in the sources of health information on e-cigarettes among US adults, 2015-2017. American Journal of Public Health, 2018:e1–e3. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30496009


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