Shifting perceptions of e-cigarette risk: A secondary analysis from a nationwide, randomized controlled clinical trial of e-cigarettes among smokers

INTRODUCTION: The Food and Drug Administration (FDA) acknowledges there is a continuum of risk for tobacco products, and that e-cigarettes are generally less harmful than combustible cigarettes. However, most US adults perceive e-cigarettes as more harmful than cigarettes, and negative perceptions have increased over time. Media coverage surrounding e-cigarette or vaping product use-associated lung injury (EVALI) may have played a role in the changing relative harm perceptions about e-cigarettes and other tobacco products. The goal of the present study was to compare relative risk perceptions for cigarettes and e-cigarettes before, during, and after EVALI. METHODS: The present paper is a secondary data analysis from a US RCT conducted from May 2018 to March of 2022. Participants self-reported demographic information and perceptions of risk for both cigarettes and e-cigarettes at baseline. Changes in relative risk before, during, and after the EVALI outbreak, were compared using a piecewise constant model. RESULTS: Relative risk perceptions of e-cigarettes were significantly greater during (p < 0.001) and after EVALI (p < 0.001) compared to before the onset of EVALI. The differences in risk perceptions between cohorts of participants differed by race (p = 0.014), in that there was a significant increase in perceived risk of harm of e-cigarettes (relative risk perceptions) during and after EVALI compared to before EVALI for non-white participants (p < 0.001, p < 0.001). CONCLUSIONS: Onset of EVALI may have impacted relative risk perceptions of e-cigarettes compared to cigarettes. Non-white smokers were more likely to experience increased perceived risk of harm of e-cigarettes (relative risk perceptions). There is a need to continue monitoring risk perceptions among smokers, as negative relative risk perceptions may hinder switching from cigarettes to e-cigarettes.