18.12 Public perceptions of the risks and benefits of e-cigarettes

Last updated:  February 2023

Suggested citation: Greenhalgh, EM, & Scollo, MM. 18.12 Public perceptions of the risks and benefits of e-cigarettes. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023. Available from:  https://www.tobaccoinaustralia.org.au/chapter-18-e-cigarettes/18-12-public-perceptions-of-the-risks-and-benefits-of-e-cigarettes 

 

Despite having some of the most restrictive e-cigarette policies in the world, poor enforcement has meant that e-cigarette use has increased dramatically among Australians in recent years, including among people who have never smoked.1 Reasons for vaping and perceptions of the benefits and harms of e-cigarettes tend to vary by age and smoking status. This section discusses:

18.12.1 Perceptions among adults

18.12.1.1 Reasons for vaping among e-cigarette users

In 2019, among Australians who had never smoked and had tried e-cigarettes, trying them out of curiosity was by far the most common reason (80%) for vaping, followed by thinking they are less harmful (13%) and taste better (12%) than tobacco cigarettes.2 People who smoke often report using e-cigarettes because they are perceived as less harmful than tobacco cigarettes, and as potentially helpful in their attempts at smoking reduction or cessation.3-15 (Refer to Section 18.7 for findings of research on efficacy for smoking cessation). In 2019 in Australia, common reasons for using e-cigarettes among smokers included helping them to quit (46%), to cut down on cigarettes (38%), or to try and prevent relapse to smoking (25%). Using them out of curiosity was also one of the most common responses (42%). Many also reported using e-cigarettes because they were perceived as less harmful (29%) and as cheaper (28%) than cigarettes.2

In the EU in 2022, people who vape also cited quitting or reducing tobacco consumption (57%), as well as believing that vaping was less harmful (37%) or cheaper (23%) than tobacco as reasons for vaping. Compared with 2017, fewer people cited quitting or reducing smoking, while more cited flavours, that they believed that vaping was less harmful, and that their friends used e-cigarettes.16 Canadian adult vapers similarly reported in 2022 quitting or cutting down smoking as the most common reasons for e-cigarette use, though younger adults were more likely to also report flavours and help with coping/stress as among their top reasons for vaping compared with older adults.17 In England, many dual users also report using e-cigarettes to obtain nicotine in settings where smoking is not permitted.18

Earlier research in the US, Canada, England and Australia found that for smokers, the top reasons for regular vaping were that it was deemed helpful for cutting down or quitting smoking, and less harmful to others. Smokers discontinued vaping if it was not satisfying, or if was perceived as not helpful for quitting or reducing cravings. For ex-smokers, current vaping was motivated by ‘enjoyment’, ‘affordability’, and ‘less harm to others’, while not needing e-cigarettes to stay quit, not being satisfying, and safety concerns motivated stopping vaping.15 

18.12.1.2 Perceptions of harm and addictiveness

A survey of Australian adults in 2022 found that about four in five (81%) agreed that e-cigarettes are highly addictive, which was significantly higher than in 2021. Levels of agreement were similar across age groups and socioeconomic status, though were slightly higher among females than males.19, 20 An analysis of Australian and UK data from the International Tobacco Control (ITC) study found that, consistent with the country’s less stringent regulations, compared to those in Australia smokers and recent ex-smokers in the UK were more likely to perceive e-cigarettes as less harmful than cigarettes.21 Another ITC study found that among current and ex-smokers in Canada, the US, England, and Australia in 2016, 37.4% allowed smoking in the home, while 60.4% of current vapers allowed vaping.22

A 2022 survey of Canadian vapers found that while most (68%) perceive smoking as harmful, nicotine e-cigarette use was ranked about the same as drinking alcohol, eating junk food, and using cannabis in terms of harm (34% compared with 33–39%).17 Studies in the EU,23 the UK,24 and the US25-29 have found that the proportion of people who perceive vaping as less harmful than smoking has decreased over time. In the US, the proportion of adults who perceived e-cigarettes to be as harmful as or more harmful than cigarettes increased substantially from 2012 to 201728 and again between 2019 and 2020.30 Media reporting on e-cigarettes also appears to affect perceptions of safety, with attitudes to the products becoming more negative among people in the wake of the EVALI outbreak (a respiratory illness linked to vaping31-34—see Section 18.6.5.4)

18.12.1.3 Support for regulations on e-cigarettes

Although vaping is becoming more common in Australia, research consistently finds high levels of support for policies that aim to limit access to and use of e-cigarettes. In 2019, about two-thirds of all Australians aged 14+ supported restrictions on the advertising of e-cigarettes and vaping in public places, and about four in five supported prohibiting sales to minors.2 In 2022, a survey of Australian adults found that the large majority agreed that e-cigarettes should be carefully regulated to stop a new generation of Australians from becoming addicted to nicotine (87%); that the promotion and marketing of e-cigarettes through social and digital media should not be allowed (84%); that the advertising of e-cigarettes in and around shops should not be allowed (82%); and vaping should not be allowed on public transport, in pubs, restaurants, or other indoor venues (87%).19 Support has also strengthened over time; between 2016 and 20192 and 2020 and 202119 the proportion of Australians supporting restrictions on the sale, advertising and use of e-cigarettes significantly increased.  

In the EU in 2021, about seven in ten people were in favour of banning the use of e-cigarettes in environments where smoking is prohibited, and about half (47%) were in favour of banning flavours in e-cigarettes.16 Between 2017 and 2021 the proportion supporting restrictions on use and flavours increased.16 In the US, there is strong public support for regulations that would potentially reduce use by children, including banning flavours.35, 36 US research has also found majority support for banning e-cigarette use in multi-unit housing.37

18.12.2 Perceptions among young people

Adolescents’ perceptions of e-cigarettes are influenced by advertising, marketing, and peer and family networks.38 Among adolescents, e-cigarettes are generally perceived as less harmful than conventional cigarettes,39 and also as less addictive.40, 41 Such perceptions of lesser harm can stem from beliefs that nicotine in e-cigarettes is less addictive, that the products contain minimal chemicals, and that secondhand aerosol is safer for bystanders.38 Perceptions of lesser harm also predict later use of e-cigarettes.33, 42 In Canada, compared with older adults, vaping is more often a recreational activity and habit in its own right among young people; many take up vaping having never regularly smoked, and they are more likely to be heavily dependent on vaping with nicotine. Adolescents report that vaping helps them to relax/cope, and that they enjoy vaping with others.17 Similarly in the EU, younger people who vape are substantially less likely to cite quitting or reducing smoking as their reason for vaping compared with older people, and more likely to cite perceptions of lesser harm, flavours, and social norms.16

Compared with non-users, youth who have used e-cigarettes perceive them to have lower health harms,38 and to also perceive flavoured products as less harmful than non-flavoured.40 Several studies in the US have found that adolescents who have lower parental education and who are from lower income families report lower perceived health risks of e-cigarettes.43, 44 Qualitative research in the UK found that adolescents perceive the products are ‘fun’, and find the diverse range of flavours particularly appealing.45 The wide range of sweet flavours is one of the most commonly cited reasons for experimentation among children, along with curiosity.32, 38, 46-49 Young adults similarly cite curiosity50 and flavours51 as common reasons for initiating e-cigarette use. 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.52

Longitudinal research in the US found that while perceptions of the harmfulness of e-cigarettes have generally increased over time among adolescents, harm perceptions were lower among ever vapers.53 Surveys in England have similarly shown that among 11–18 year olds, the proportion who thought that vaping was less harmful than smoking declined between 2015 and 2020, though increased slightly in 2021.33

See Section 18.9 for a detailed discussion of influences on the uptake of e-cigarettes among young people.

18.1.3 Perceptions among health professionals

Surveys of health professionals have found uncertainty regarding the safety and efficacy of e-cigarettes. A review of the beliefs and practices of healthcare professionals found that although most believe that e-cigarettes are less harmful than cigarettes, they also express concern about the health risks of e-cigarettes, and uptake and ‘gateway effects’ among young people. While most do not proactively recommend e-cigarette use, they are more likely to support use among patients with smoking related co-morbidities, heavy smokers with previous unsuccessful quit attempts, or patients who express interest in trying them.54 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.55 An international review of pharmacists’ perceptions of e-cigarettes similarly found a lack of knowledge and confidence regarding the use of e-cigarettes as a cessation aid.56 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.57 Among a sample of Australian alcohol and other drug healthcare providers, only a minority agreed that e-cigarettes could help smokers quit (30%), that e-cigarettes were safer than tobacco smoking (25%), and that they would recommend e-cigarettes (19%).58

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.59 Among medical students in the UK, although most (90%) felt that e-cigarettes were beneficial for reducing smoking, only just over half (56%) reported that they would recommend them to patients and many (61%) reported a lack of confidence in giving advice about e-cigarettes.60 In the US, one study found that recommending e-cigarettes to patients appeared to be more common among physicians who were ex-smokers themselves, and also to older heavy smokers with multiple unsuccessful quit attempts.61 A recent systematic review found that GPs hold mixed views regarding e-cigarettes. While patients are increasingly seeking information and advice about e-cigarettes for smoking cessation, most GPs believed their knowledge and the information about e-cigarettes was insufficient to provide advice and guidance about their use as a cessation aid.62

People generally report greater trust in medical professionals and public health organisations for providing accurate information on e-cigarettes than those with commercial interests; health professionals therefore may be able to effectively counter misleading e-cigarette promotion and improve public knowledge.63  

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated June 2024)

References 

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