England remains the country in which the government and (most of the) health establishment continue to aggressively promote e-cigarettes as a better alternative to cigarettes. As a result, Sarah Jackson and her colleagues were concerned about the results of their latest survey of smokers’ attitudes towards e-cigarettes, reported in their paper Trends in Harm Perceptions of E-Cigarettes vs Cigarettes Among Adults Who Smoke in England, 2014-2023, which found that among British smokers “harm perceptions of e-cigarettes have worsened substantially over the last decade, such that in 2023, most (57.0%) believed e-cigarettes to be equally (33.7%) or more (23.3%) harmful than cigarettes.” The fraction of smokers who think e-cigarettes are less harmful than cigarettes has been falling over time (chart above, which is from their paper).
In fact, this increasing concern about the health risks of e-cigarettes — as opposed to thinking that they are safer than cigarettes — is consistent with recent evidence showing that for some diseases e-cigarettes have similar risks to cigarettes nearly as high for others and that dual is use riskier than smoking alone.
Jackson and colleagues express concern that, “If people who smoke think vaping is equally or more harmful than smoking, they may be less inclined to try and switch to vaping.” Of course, the actual disease data suggests that being less inclined to trying to switch to vaping is a good thing, especially since many attempted switchers end up dual users.
Jackson and colleagues also not that, “in April 2023, the English government announced a national swap to stop campaign, which aims to offer 1 million people a free vaping starter kit with behavioral support, to help them quit smoking. Strategies such as these could be undermined if people who smoke are unwilling to try vaping because of safety concerns.” This is particularly concerning because giving people free e-cigarettes creates 2-3 dual users for every smoker who switches. And dual use is more dangerous than just smoking. Based on actual disease risks it would be a good thing if British smokers took a pass on the national swap campaign.
They also express concern that, “if people who both smoke and vape (dual users) think the risks are similar, they may not see any benefit of stopping smoking and instead continue both behaviors.” The appropriate response to dual use is to educate smokers that dual use is riskier than smoking or vaping alone.
It’s time for the government and (most of the) health establishment to catch up with the public, update their thinking on e-cigarettes based on actual disease outcomes, and stop promoting e-cigarettes as a harm reduction technique.
Here is the abstract of their paper:
Objective To examine time trends in harm perceptions of e-cigarettes compared with combustible cigarettes among adults who smoke.
Design, Setting, and Participants This nationally representative monthly cross-sectional survey study was conducted from November 2014 to June 2023 in England. Participants were adults who currently smoke.
Main Outcomes and Measures Participants were asked whether they thought e-cigarettes were less harmful, equally harmful, or more harmful than cigarettes, or did not know, with the proportion responding less harmful (vs all other responses) as the primary outcome. Logistic regression was used to test associations between survey wave and participants’ perceptions of the harms of e-cigarettes.
Results Data were collected from 28 393 adults who smoke (mean [SD] age, 43.5 [17.3] years; 13 253 [46.7%] women). In November 2014, 44.4% (95% CI, 42.0%-46.8%) thought e-cigarettes were less harmful than cigarettes, 30.3% (95% CI, 28.2%-32.6%) thought e-cigarettes were equally harmful, 10.8% (95% CI, 9.4%-12.3%) thought they were more harmful, and 14.5% (95% CI, 12.9%-16.4%) did not know. However, by June 2023, the proportion who thought e-cigarettes were less harmful had decreased by 40% (prevalence ratio, 0.60; 95% CI, 0.55-0.66), and the proportion who thought e-cigarettes were more harmful had more than doubled (prevalence ratio, 2.16; 95% CI, 1.84-2.54). Changes over time were nonlinear: late 2019 saw a sharp decline in the proportion who thought e-cigarettes were less harmful and increases in the proportions who thought they were equally or more harmful. These changes were short-lived, returning to pre-2019 levels by the end of 2020. However, perceptions worsened again from 2021 up to the end of the study period: the proportion who thought e-cigarettes were more harmful increased to a new high, and the proportion who thought e-cigarettes were less harmful decreased to levels comparable to those in late 2019. As a result, in June 2023, the perception that e-cigarettes were equally as harmful as cigarettes was the most commonly held view among adults who smoke (33.7%; 95% CI, 31.4%-36.1%), with roughly similar proportions perceiving e-cigarettes to be less (26.7%; 95% CI, 24.6%-28.9%) and more (23.3%; 95% CI, 21.1%-25.7%) harmful.
Conclusions and Relevance This survey study of adults who smoke in England found that harm perceptions of e-cigarettes have worsened substantially over the last decade, such that most adults who smoked in 2023 believed e-cigarettes to be at least as harmful as cigarettes. The timing of the 2 most notable changes in harm perceptions coincided with the e-cigarette, or vaping product, use-associated lung injury outbreak in 2019 and the recent increase in youth vaping in England since 2021.
The full citation is: Jackson SE, Tattan-Birch H, East K, Cox S, Shahab L, Brown J. Trends in Harm Perceptions of E-Cigarettes vs Cigarettes Among Adults Who Smoke in England, 2014-2023. JAMA Netw Open. 2024;7(2):e240582. doi:10.1001/jamanetworkopen.2024.0582. It is available here.
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