18B.11 Public perceptions of e-cigarettes

Last updated:  April 2020

Suggested citation: Greenhalgh, EM, & Scollo, MM. InDepth 18B: Electronic cigarettes (e-cigarettes). In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2020. Available from:  http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18b-e-cigarettes


Current and former smokers—who comprise the majority of e-cigarette users—generally perceive e-cigarettes as less harmful than tobacco cigarettes, and as potentially helpful in their attempts at smoking reduction or cessation.1-13  (Refer Section 18B.7 for findings of research on efficacy for smoking cessation). Survey research in NSW found that the most common reasons for using e-cigarettes among smokers over 30 was “to help me quit” and to “cut down” smoking; for younger adults it was “because they are not as bad for your health as cigarettes”.14  Completely switching to e-cigarettes appears to be more common among dual users who perceive e-cigarettes as less harmful than cigarettes.15 An analysis of Australian and UK data from the 2013 International Tobacco Control (ITC) Four-Country project 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.16 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.17 Continued use of e-cigarettes among smokers appears to depend on whether the products live up to expectations regarding perceptions of short-term health improvements and ability to mimic smoking behaviours.18 ITC research 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.13 

Among the general public, research in 2013–14 in the US found that fewer than half (40.7%) of adults believed that e-cigarettes were less harmful than cigarettes, although they were most likely to be seen as less harmful compared with other products (such as hookah and cigars).19 Many also report having rules prohibiting e-cigarette use inside homes and vehicles.20 Another study in the US found that more positive affect towards e-cigarettes was associated with lower perceived risks, which in turn was associated with higher odds of being a current e-cigarette user.21 In a sample of young Australian adults, the majority believed e-cigarettes have some level of harm (72%), and just over half believed them to be addictive (57%); however many did not know whether e-cigarettes are harmful (20%) or addictive (34%). Forty-two per cent believed e-cigarettes are effective cessation aids. Smokers and users tended to be more positive about the products.22

Among adolescents, e-cigarettes are generally perceived as less harmful than conventional cigarettes,23 and also as less addictive.24, 25  Such perceptions of lesser harm appear to predict later use of e-cigarettes.26 One US study found that compared with never-users, youth who had ever or currently used e-cigarettes believed them to be not at all harmful or addictive, and were more likely to report flavoured products were less harmful than non-flavoured.24 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.27, 28 Qualitative research in the UK found that adolescents perceive the products are ‘fun’, and find the diverse range of flavours particularly appealing.29 The wide range of sweet flavours is one of the most commonly cited reasons for experimentation among children, along with curiosity.30-33 Young adults similarly cite curiosity34 and flavours35 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.18 In the US, there is strong public support for regulations that would potentially reduce use by children, including banning flavours.36, 37

Despite the general beliefs about potential for reduced health risk noted above, perceptions of harm appear to be increasing. Research in the EU found that between 2012 and 2014, the perception that e-cigarettes are harmful increased from 27.1% to 51.6%, although there were major differences between member states.38 Studies in the UK39 and the US40-44 have similarly found that the proportion of people who perceive vaping as less harmful than smoking has decreased over time. One found that the proportion of people who did not think vaping could help people quit, that thought vaping was addictive, and that thought vape was comparable to secondhand smoke increased between 2015 and 2016.40 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 2017.43

Surveys of health professionals have also 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.45 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.46 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.47 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.48 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.49



Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated August 2022)



1. Adkison SE, O'Connor RJ, Bansal-Travers M, Hyland A, Borland R, et al. Electronic nicotine delivery systems: International tobacco control four-country survey. American Journal of Preventive Medicine, 2013; 44(3):207-15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23415116

2. Bauhoff S, Montero A, and Scharf D. Perceptions of e-cigarettes: A comparison of adult smokers and non-smokers in a Mechanical Turk sample. American Journal of Drug and Alcohol Abuse, 2017; 43(3):311-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27712126

3. Tomashefski A. The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review. Journal of the American Association of Nurse Practitioners, 2016; 28(9):510-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26997487

4. Czoli CD, Fong GT, Mays D, and Hammond D. How do consumers perceive differences in risk across nicotine products? A review of relative risk perceptions across smokeless tobacco, e-cigarettes, nicotine replacement therapy and combustible cigarettes. Tobacco Control, 2017; 26(e1):e49-e58. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27625408

5. Pepper JK, Emery SL, Ribisl KM, Rini CM, and Brewer NT. How risky is it to use e-cigarettes? Smokers' beliefs about their health risks from using novel and traditional tobacco products. Journal of Behavioral Medicine, 2015; 38(2):318-26. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25348584

6. Xu Y, Guo Y, Liu K, Liu Z, and Wang X. E-cigarette awareness, use, and harm perception among adults: A meta-analysis of observational studies. PLoS One, 2016; 11(11):e0165938. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27861501

7. Couraud S, Cortot AB, Pivot XB, Touboul C, Lhomel C, et al. Beliefs and behavior regarding e-cigarettes in a large cross-sectional survey. Preventive Medicine Reports, 2018; 10:332-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29868388

8. Goldberg RL, Dankiewicz C, and Cataldo JK. Older smokers' beliefs about e-cigarettes and intent to quit conventional cigarettes. Journal of Gerontological Nursing, 2018; 44(12):17-24. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30484844

9. Merry S and Bullen CR. E-cigarette use in New Zealand-a systematic review and narrative synthesis. New Zealand Medical Journal, 2018; 131(1470):37-50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29470471

10. Truman P, Glover M, and Fraser T. An online survey of New Zealand vapers. International Journal of Environmental Research and Public Health, 2018; 15(2). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29382129

11. Erku DA, Gartner CE, Tengphakwaen U, Morphett K, and Steadman KJ. Nicotine vaping product use, harm perception and policy support among pharmacy customers in Brisbane, Australia. Drug Alcohol Rev, 2019; 38(6):703-11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31486151

12. Riahi F, Rajkumar S, and Yach D. Tobacco smoking and nicotine delivery alternatives: Patterns of product use and perceptions in 13 countries. F1000Res, 2019; 8:80. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31131094

13. Yong HH, Borland R, Cummings KM, Gravely S, Thrasher JF, et al. Reasons for regular vaping and for its discontinuation among smokers and recent ex-smokers: Findings from the 2016 ITC four country smoking and vaping survey. Addiction, 2019; 114 Suppl 1:35-48. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30821861

14. Dunlop S, Lyons C, Dessaix A, and Currow D. How are tobacco smokers using e-cigarettes? Patterns of use, reasons for use and places of purchase in New South Wales. Medical Journal of Australia, 2016; 204(9):355. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27169972

15. Persoskie A, O'Brien EK, and Poonai K. Perceived relative harm of using e-cigarettes predicts future product switching among US adult cigarette and e-cigarette dual users. Addiction, 2019; 114(12):2197-205. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31278802

16. Yong HH, Borland R, Balmford J, Hitchman SC, Cummings KM, et al. Prevalence and correlates of the belief that electronic cigarettes are a lot less harmful than conventional cigarettes under the different regulatory environments of Australia and the United Kingdom. Nicotine & Tobacco Research, 2017; 19(2):258-63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27190403

17. Nahhas GJ, Braak D, Cummings KM, Heckman BW, Alberg AJ, et al. Rules about smoking and vaping in the home: Findings from the 2016 international tobacco control four country smoking and vaping survey. Addiction, 2019; 114 Suppl 1:107-14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30710468

18. Romijnders K, van Osch L, de Vries H, and Talhout R. Perceptions and reasons regarding e-cigarette use among users and non-users: A narrative literature review. International Journal of Environmental Research and Public Health, 2018; 15(6). Available from: https://www.ncbi.nlm.nih.gov/pubmed/29882828

19. Fong GT, Elton-Marshall T, Driezen P, Kaufman AR, Cummings KM, et al. US adult perceptions of the harmfulness of tobacco products: Descriptive findings from the 2013-14 baseline wave 1 of the path study. Addictive Behaviors, 2019; 91:180-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30502927

20. Gentzke AS, Homa DM, Kenemer JB, Gomez Y, and King BA. Rules to prohibit the use of electronic vapor products inside homes and personal vehicles among adults in the US, 2017. Preventive Medicine, 2018; 114:47-53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29857024

21. Popova L, Owusu D, Weaver SR, Kemp CB, Mertz CK, et al. Affect, risk perception, and the use of cigarettes and e-cigarettes: A population study of US adults. BMC Public Health, 2018; 18(1):395. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29566752

22. Jongenelis MI, Kameron C, Rudaizky D, Slevin T, and Pettigrew S. Perceptions of the harm, addictiveness, and smoking cessation effectiveness of e-cigarettes among Australian young adults. Addictive Behaviors, 2019; 90:217-21. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30447513

23. East K, Brose LS, McNeill A, Cheeseman H, Arnott D, et al. Harm perceptions of electronic cigarettes and nicotine: A nationally representative cross-sectional survey of young people in Great Britain. Drug and Alcohol Dependence, 2018; 192:257-63. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30300799

24. Cooper M, Harrell MB, Perez A, Delk J, and Perry CL. Flavorings and perceived harm and addictiveness of e-cigarettes among youth. Tobacco Regulatory Science, 2016; 2(3):278-89. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27722185

25. Cooper M, Loukas A, Harrell MB, and Perry CL. College students' perceptions of risk and addictiveness of e-cigarettes and cigarettes. J Am Coll Health, 2017; 65(2):103-11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27805472

26. Parker MA, Villanti AC, Quisenberry AJ, Stanton CA, Doogan NJ, et al. Tobacco product harm perceptions and new use. Pediatrics, 2018; 142(6). Available from: https://www.ncbi.nlm.nih.gov/pubmed/30397167

27. Kong G, Simon P, Mayer ME, Barrington-Trimis JL, Pacek LR, et al. Harm perceptions of alternative tobacco products among US adolescents. Tobacco Regulatory Science, 2019; 5(3):242-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31840041

28. Vu TT, Groom A, Hart JL, Tran H, Landry RL, et al. Socioeconomic and demographic status and perceived health risks of e-cigarette product contents among youth: Results from a national survey. Health Promotion Practice, 2020; 21(1_suppl):148S-56S. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31908196

29. Hilton S, Weishaar H, Sweeting H, Trevisan F, and Katikireddi SV. E-cigarettes, a safer alternative for teenagers? A UK focus group study of teenagers' views. BMJ Open, 2016; 6(11):e013271. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27852721

30. Measham F, O’Brien K, and Turnbull G. “Skittles & red bull is my favourite flavour”: E-cigarettes, smoking, vaping and the changing landscape of nicotine consumption amongst British teenagers – implications for the normalisation debate. Drugs: Education, Prevention and Policy, 2016; 23(3):224-37. Available from: http://dx.doi.org/10.1080/09687637.2016.1178708

31. Kong G, Morean ME, Cavallo DA, Camenga DR, and Krishnan-Sarin S. Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults. Nicotine & Tobacco Research, 2015; 17(7):847-54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25481917

32. Harrell MB, Weaver SR, Loukas A, Creamer M, Marti CN, et al. Flavored e-cigarette use: Characterizing youth, young adult, and adult users. Preventive Medicine Reports, 2017; 5:33-40. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27896041

33. Pepper JK, Ribisl KM, and Brewer NT. Adolescents' interest in trying flavoured e-cigarettes. Tobacco Control, 2016; 25(Suppl 2):ii62-ii6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27633762

34. Kinouani S, Leflot C, Vanderkam P, Auriacombe M, Langlois E, et al. Motivations for using electronic cigarettes in young adults: A systematic review. Substance Abuse, 2019:1-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31638872

35. Landry RL, Groom AL, Vu TT, Stokes AC, Berry KM, et al. The role of flavors in vaping initiation and satisfaction among US adults. Addictive Behaviors, 2019; 99:106077. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31437770

36. Campaign for Tobacco-Free Kids. New poll: Voters overwhelmingly support trump administration’s plan to take flavored e-cigarettes off the market. Tobacco Free Kids,  2019. Available from: https://www.tobaccofreekids.org/press-releases/2019_10_10_ecig_poll

37. Czaplicki L, Perks SN, Liu M, Cuccia A, Patel M, et al. Support for e-cigarette and tobacco control policies among parents of adolescents. Nicotine & Tobacco Research, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31793996

38. Filippidis FT, Laverty AA, Gerovasili V, and Vardavas CI. Two-year trends and predictors of e-cigarette use in 27 European union member states. Tobacco Control, 2017; 26(1):98-104. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27220621

39. McNeill A, Brose LS, Calder R, Bauld L, and Robson D. Evidence review of e-cigarettes and heated tobacco products 2018: A report commissioned by Public Health England. Public Health England, London: Public Health England, 2018. Available from: https://www.gov.uk/government/publications/e-cigarettes-and-heated-tobacco-products-evidence-review.

40. Mincer J. US e-cigarette use stalls as health concerns grow: Reuters/ipsos poll. Reuters,  2016. Available from: http://uk.reuters.com/article/us-usa-ecigarettes-poll-idUKKCN0YF0DE

41. Majeed BA, Weaver SR, Gregory KR, Whitney CF, Slovic P, et al. Changing perceptions of harm of e-cigarettes among US adults, 2012-2015. American Journal of Preventive Medicine, 2017; 52(3):331-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28341303

42. Huerta TR, Walker DM, Mullen D, Johnson TJ, and Ford EW. Trends in e-cigarette awareness and perceived harmfulness in the US. American Journal of Preventive Medicine, 2017; 52(3):339-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27890516

43. Huang J, Feng B, Weaver SR, Pechacek TF, Slovic P, et al. Changing perceptions of harm of e-cigarette vs cigarette use among adults in 2 US national surveys from 2012 to 2017. JAMA Netw Open, 2019; 2(3):e191047. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30924893

44. Nyman AL, Huang J, Weaver SR, and Eriksen MP. Perceived comparative harm of cigarettes and electronic nicotine delivery systems. JAMA Netw Open, 2019; 2(11):e1915680. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31747029

45. Erku DA, Gartner CE, Morphett K, and Steadman KJ. Beliefs and self-reported practices of healthcare professionals regarding electronic nicotine delivery systems (ends): A mixed-methods systematic review and synthesis. Nicotine & Tobacco Research, 2019. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30938442

46. Erku DA, Gartner CE, Do JT, Morphett K, and Steadman KJ. Electronic nicotine delivery systems (e-cigarettes) as a smoking cessation aid: A survey among pharmacy staff in Queensland, Australia. Addictive Behaviors, 2019; 91:227-33. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30224155

47. Luxton NA, Shih P, and Rahman MA. Electronic cigarettes and smoking cessation in the perioperative period of cardiothoracic surgery: Views of Australian clinicians. International Journal of Environmental Research and Public Health, 2018; 15(11). Available from: https://www.ncbi.nlm.nih.gov/pubmed/30405035

48. Gravely S, Thrasher JF, Cummings KM, Ouimet J, McNeill A, et al. Discussions between health professionals and smokers about nicotine vaping products: Results from the 2016 ITC four country smoking and vaping survey. Addiction, 2019; 114 Suppl 1:71-85. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30548374

49. Owusu D, Weaver SR, Yang B, Ashley DL, and Popova L. Trends in trust in the sources of health information on e-cigarettes among US adults, 2015-2017. American Journal of Public Health, 2018:e1-e3. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30496009