It's taken a few years, but American adults are realizing something family physicians already knew: E-cigarettes are bad for you.
Despite the marketing crush employed by the makers of JUUL and other devices like it, new research(jamanetwork.com) published March 29 in JAMA Network Open shows that the number of Americans who think e-cigarettes are as harmful as traditional cigarettes, if not more harmful, has increased substantially between 2012 and 2017.
Survey Details and Results
The study reported on the findings of two national surveys: the Tobacco Products and Risk Perceptions Survey (TPRPS) and the National Cancer Institute's Health Information National Trends Survey (HINTS).
Researchers analyzed responses from more than 24,000 people who participated in the TPRPS between 2012 and 2017, asking them whether they had ever heard of e-cigarettes and whether they thought e-cigarettes were less harmful, about the same, or more harmful than smoking regular cigarettes.
- Results from two surveys showed a substantial change in American adults' perceptions of the risks of e-cigarette use between 2012 and 2017.
- Analysis of the survey results indicated that the percentage of adults who thought e-cigarettes were less harmful than traditional cigarettes dropped markedly.
- During the same period, the percentage of adults who thought e-cigarettes were as harmful as or more harmful than traditional cigarettes increased considerably.
Similarly, responses from nearly 11,000 U.S. adults who participated in the HINTS during the same period were included in the researchers' analysis. HINTS participants were asked whether they thought using e-cigarettes was much less harmful, less harmful, just as harmful, more harmful, or much more harmful compared to smoking cigarettes.
Analysis of TPRPS results showed that the proportion of adults who perceived e-cigarettes as less harmful than traditional cigarettes declined from 39.4% in 2012 to 33.9% in 2017. During the same period, the proportion of adults who perceived e-cigarettes and traditional cigarettes as equally harmful more than tripled, rising from 11.5% to 36.4%. Likewise, the proportion of adults who viewed e-cigarettes as more harmful than traditional cigarettes more than tripled, from 1.3% to 4.3%.
Analysis of HINTS data showed that in 2012, 50.7% of adults thought using e-cigarettes was less or much less harmful than smoking traditional cigarettes, but that figure declined to 34.5% in 2017. The proportion of adults who thought e-cigarettes were as harmful as traditional cigarettes increased from 46.4% to 55.6%, and the number of adults who thought e-cigarettes were more or much more harmful than traditional cigarettes jumped more than threefold, from 2.8% to 9.9%.
These percentages differed slightly depending on whether the person being surveyed was a current or former smoker or had never smoked.
For the TPRPS participants, the percentage of current, former and never smokers who thought e-cigarettes were as harmful as or more harmful than traditional cigarettes all increased significantly from 2012 to 2017. The percentage of never and current smokers who thought e-cigarettes were less harmful decreased significantly during the same period, but in former smokers, no significant decline was seen.
Similar results were seen in the HINTS survey. The proportion of adults who perceived e-cigarettes as less harmful than regular cigarettes decreased significantly from 2012 to 2017 regardless of whether the person surveyed was a current, former or never smoker, and the percentage of those who perceived e-cigarettes as more harmful than regular cigarettes increased significantly in each smoking category.
"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," the researchers concluded. "Our results underscore the urgent need for accurate communication of the scientific evidence on the health risks of e-cigarettes and the importance of clearly differentiating the absolute harm from the relative harm of e-cigarettes."
Newer Research Backs Public Perception
This analysis of the TPRPS and HINTS findings is all the more important in light of a January 2018 report(www.nationalacademies.org) from the National Academies of Science, Engineering and Medicine, which concluded, among other things: "The evidence about harm reduction suggests that across a range of studies and outcomes, e-cigarettes pose less risk to an individual than combustible tobacco cigarettes."
It can't be overlooked that the authors of the National Academies report stressed at the time that the long-term health effects of e-cigarettes were unclear. Since that report's publication, more recent studies have linked e-cigarette use to an increased risk of myocardial infarction,(www.ncbi.nlm.nih.gov) stroke,(www.ahajournals.org) COPD(www.atsjournals.org) and other respiratory disorders(www.ncbi.nlm.nih.gov) even after controlling for cigarette smoking and other risk factors.
What About E-Cigarettes and Youth?
Although the current study focused on perceptions of e-cigarette use among U.S. adults, with vaping skyrocketing among high school and middle school students,(www.fda.gov) there's certainly cause to hope the same assessment takes hold in younger Americans.
In an editorial(jamanetwork.com) that accompanied the JAMA Network Open study, researcher Stanton Glantz, Ph.D., called the increased perception of risk associated with e-cigarettes "an important element" for reducing their use by American youth. Previous research(www.ncbi.nlm.nih.gov) has shown that youth who think e-cigarettes do not cause harm or are less harmful than traditional cigarettes are more likely to use them than youth with negative views of e-cigarettes.
"From this perspective, the declining public perception that e-cigarettes are less harmful than cigarettes is a good thing," Glantz said.
Suggestions for Discussing E-Cigarette Use
Kaitlyn Perry, M.P.H., a population health strategist with the Academy's Health of the Public and Science Division, told AAFP News that family physicians can use the survey findings as an opportunity to talk with their patients about the use of tobacco products and e-cigarettes.
"Family physicians should screen all patients for e-cigarettes in addition to screening for tobacco use," said Perry. "Even if the patient indicates they do not use tobacco products, they may be using e-cigarettes.
"It also is important for family physicians to tell patients that most e-cigarettes contain nicotine and are still addictive," she added. "Many people don't consider e-cigarettes tobacco products or even know that the majority of e-cigarettes contain nicotine."
Perry noted that the AAFP supports the USPSTF recommendations on behavioral and pharmacotherapeutic interventions for tobacco smoking cessation in adults, including pregnant women.
The AAFP has resources on tobacco cessation that also apply to patients who use e-cigarettes. Perry recommended that family physicians visit Ask and Act, the AAFP's tobacco cessation program, as well as the Academy's Tobacco and Nicotine Cessation Toolkit.
Finally, Perry stressed the important role family physicians can play in ensuring teenagers and young adults understand the risks of e-cigarettes.
"Family physicians should also educate parents and adolescents about e-cigarettes to prevent lifelong nicotine addiction," she said. "There is no safe level of nicotine exposure for youth, and evidence indicates youth who use e-cigarettes are more likely to start smoking traditional cigarettes than those who don't use e-cigarettes."
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