Although e-cigarettes are currently available on the market, for a variety of reasons, such as a lack of application guidance and unclear deadlines, no e-cigarette has yet been formally approved by the U.S. Food and Drug Administration. When the FDA does start the process of application review, they will be required to consider whether the product in question is “appropriate for the protection of public health.” This is because, pursuant to the Family Smoking Prevention and Tobacco Control Act of 2009, approval of new or innovative tobacco products depends upon this standard being met and thus far, the FDA appears to take the position that e-cigarettes are largely harmful. For example, despite an abundance of evidence that indicates e-cigarettes are more favorable than their combustible counterparts, the agency has nevertheless signaled an intention to privilege concerns that their existence may encourage use in those who would otherwise not use nicotine products. However, while the risks to non-smokers—including the risk of uptake—are still under debate, the benefits to current smokers who switch are much clearer.

It is therefore of key importance to examine the actual factors that may encourage or discourage the use of e-cigarettes—in both current and nonsmokers. And, in light of this, a recent study conducted by Cosima Hoetger et al. sought to examine potential policy conditions that may encourage the use of e-cigarettes as a safer alternative to combustible ones. Using an online experimental survey, smokers and non-smokers were divided into three regulatory domains regarding nicotine strength, flavor availability and health messaging. They were then asked about the likelihood under certain conditions in each category that they would try an e-cigarette. So, for example, they were offered high- and low-nicotine options or certain flavor choices (tobacco, menthol or fruit) and then asked whether, given that choice, they would opt to try one. In terms of health messaging, participants were offered two potential benefits to choose from—reduced overall harm (as compared to combustible cigarettes) or reduced carcinogen exposure. Participants that answered “definitely not” were considered ‘not susceptible’ and participants that answered in the affirmative were considered ‘susceptible.’

In terms of overall findings, the study reported that e-cigarette susceptibility was higher among smokers than non-smokers in all domains. In the nicotine content domain, smokers were 29.8 times more likely to indicate interest in using e-cigarettes than non-smokers. Current smokers in the health messaging domain were 43.9 times more likely to indicate an interest in using the product compared to non-smokers. And finally, when asked about flavors of e-cigarettes, smokers were 9.6 times more likely to indicate interest. Such findings would appear to work counter to the assumption that e-cigarettes will tempt non-users to use.

Other important discoveries emerged. First, current smokers were significantly more susceptible to high-nicotine-content e-cigarettes, while they were not significantly susceptible to low-nicotine ones. This suggests that given previous, regular smoking, the absence of a higher nicotine option in e-cigarettes likely would not induce current smokers to switch. Second, current smokers were not more likely to express interest in menthol flavors and were less likely to indicate interest in fruit flavors. On its face, this may suggest that the availability of flavored e-cigarettes has little bearing on switching behavior. And while that may be true in terms of the initial switch—after all, it is understandable that current smokers of tobacco-flavored cigarettes would be more interested in tobacco-flavored e-cigarettes—there is also evidence to suggest that over time, e-cigarette users come to prefer non-tobacco flavors and perhaps more importantly, use them to dissociate the effect of nicotine from the tobacco flavors associated with most combustible products.

And finally, smokers were 15.3 times more likely to express interest when presented with a message of reduced carcinogen exposure compared to a message of overall reduced harm. Since a major benefit of e-cigarettes is the absence of the majority of carcinogens present in combustible cigarette smoke, such a finding would suggest that e-cigarettes may be able to address the very health concerns that may encourage current smokers to switch to the safer alternative. But moreover, participants’ preference for the more specific harm messaging suggests that how e-cigarettes are labeled may make them vastly more effective in achieving positive health outcomes. For example, currently, the FDA has not awarded any product the status of a “modified-risk tobacco product” that allows manufacturers to make specific health claims about their product. This means that currently, all tobacco products, including e-cigarettes, that are available on the market are classified much the same way as combustible cigarettes are—regardless of relative or absolute risk. An official classification of the difference may do much to encourage smokers to switch. Moreover, labels should not be generic in claiming “reduced health risks,” but rather must make a specific claim, such as: “Using [this product] instead of cigarettes puts you at a lower risk of mouth cancer, heart disease and lung cancer.” Although this specific wording (for example) has not yet been tested, Hoetger et al.’s work suggests that specificity with respect to positive health outcomes provokes interest in switching, and that FDA expediency in approving appropriate claims would benefit smokers.

In addition to measures of susceptibility, the study also assessed all participants’ perceptions of harm and addiction compared to regular, non-menthol cigarettes. Overall, the study found that participants perceived e-cigarettes to be as harmful as combustible cigarettes and as addictive. When comparing different features of e-cigarettes within each domain, e-cigarettes with both low and high nicotine concentrations were perceived as more harmful than e-cigarettes without nicotine (high-nicotine e-cigarettes were perceived as more dangerous than low-nicotine ones). With respect to flavors, the menthol flavor was considered to be more dangerous than the tobacco flavor. Fruit flavors were not considered more dangerous. In terms of health messaging, participants did not have increased perception of harm between the two options (reduced overall harm versus reduced carcinogen exposure specifically).

These findings align with previous studies that show that the perception of the overall harm from smoking is strongly associated with misconceptions of nicotine. Based on incorrect and otherwise faulty information, such opinions demonstrate the desperate need for public health education regarding the actual risks associated with cigarettes versus the risks associated with their active ingredient.

Overall, Hoetger et al. does much to elucidate common misperceptions that stymie wider adoption of e-cigarettes as a harm reduction tool. The study also helps to provide actual data to refute the argument that the availability of e-cigarettes poses more of a danger to current non-smokers that it does a benefit to those who smoke. Accordingly, findings such as these should be considered both by the public and in the regulatory space so that current smokers and the FDA can make informed decisions about the use and approval of e-cigarettes as an effective and safer alternative to combustible ones.

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