Tobacco Harm Reduction: Risk Perceptions

17 September 2024

CHAPTER 5 . OUR SMOKELESS PRODUCTS

Tobacco Harm Reduction:
Risk Perceptions

Our purpose of A Better Tomorrow™ through Building a Smokeless World is underpinned by Tobacco Harm Reduction (THR), which is based on adult smokers switching to lower risk^*† profile tobacco and nicotine products. While much progress has been made, one of the most significant barriers to adult smokers switching is their perception of the risk of Smokeless Products.

Quite simply, the more adult smokers who perceive the risk of Smokeless Products to be lower than that of smoking, the more likely they will be to switch.

Vapour Products do not contain tobacco and operate at temperatures much lower than that in a burning cigarette, emitting fewer and lower amounts of harmful chemicals relative to cigarette smoke. Despite significant support for the reduced-risk nature of Vapour Products, many adult smokers perceive them to be equally or more risky than cigarettes, in part due to the following reasons:

E-cigarette or vaping use-associated lung injury (EVALI) crisis when adulterated illicit e-cigarettes were sold and used in parts of the U.S. in 2019;
Certain manufacturers using ingredients that have links to harm (e.g. Diacetyl and Bronchiolitis obliterans ‘popcorn lung’);
They contain nicotine, which is misperceived as being the principal cause of smoking-related disease; and
Historical association of nicotine and cigarette smoke, conflating the risks of nicotine.

What is risk perception?

Risk perception refers to people’s subjective judgements about the likelihood of negative occurrences such as injury, illness, disease, and death. Risk perception is important in health and risk communication because it determines which hazards people care about and how they deal with them. Risk perception has two main dimensions: the cognitive dimension, which relates to how much people know about and understand risks; and the emotional dimension, which relates to how they feel about them.^[1]

How is risk perception measured?

Risk perception is typically measured using questionnaires, which can be administered either longitudinally (e.g. asking the same group about their risk perception over a period of time) or cross-sectionally (e.g. taking a random sample of the population at a single time point). The questionnaire can be administered either with or without stimulus (e.g. giving the subjects information about Smokeless Products relative to cigarettes).

Figure 1. UK adults' perception of harm from e-cigarettes, Great Britain (2013-2023)^[2]

"Despite NASEM’s [National Academies of Science, Engineering and Medicine] conclusions that complete substitution of cigarettes with e-cigarettes reduces exposure to numerous toxicants and carcinogens...[only] 11.4% of Americans perceiv[e] e-cigarettes to be less harmful. Similarly, many physicians also believe that all tobacco products [including e-cigarettes] are equally harmful."

Dr Brian King

Director, Center for Tobacco Products, U.S. FDA^[3]

Table 1. Risk perceptions of U.S. adult smokers(%)^[4]

Product comparison	Don’t know	Less harmful	About the same	More harmful	Total misperception
LNC vs CC	0.56	13.13	82.08	4.23	17.92^{^}
Snus vs CC	2.58	6.09	64.12	27.21	93.91^{^^}
EC vs CC	2.17	18.69	70.18	8.96	81.31^{^^}
EC vs NRT	2.26	11.04	64.61	22.09	77.91^{^^^}

LNC = Low Nicotine Cigarette;

CC = Combustible Cigarette;

EC = Electronic Cigarette;

NRT = Nicotine Replacement Therapy

^Total = Don't know + Less harmful + More harmful

^^Total = Don't know + About the same + More harmful

^^^Total = Don't know + Less harmful + About the same

Risk perception of THR products by different stakeholder groups

(i) Adult perceptions of THR products

The UK is entering its second decade of transformation with Vapour Products being available for sale since the early 2010s. The trend of risk perception of Vapour Products is profound,^[2] with the number of adult consumers who perceive Vapour Products as being less risky than smoking dropping from 42% to 34% over the last decade. Contrary to this, the number of adult consumers who perceive Vapour Products as being more risky than smoking has increased from 8.1% to 43% over the last decade (Figure 1). Those who state they don’t know has also dropped from 38% to 21%, meaning that while adult consumers are making more decisions on the risk profile of Vapour Products compared to smoking, these decisions appear to be running contrary to the messaging of the mainstream UK public health authorities.

In a similar manner, researchers in the U.S. surveyed 33,822 adults (Wave 4 of PATH survey),^[4] to assess their perceptions of risk between different types of products (Table 1). The findings were profound with respondents stating that all three product types assessed, snus, e-cigarettes and Nicotine Replacement Therapy, were about the same level of risk or more harmful than cigarettes. This outcome is despite all the epidemiological evidence from Sweden on snus, the public health support for the reduced risk profile of e-cigarettes and the fact that Nicotine Replacement Therapy is medically regulated, and therefore must demonstrate its safety profile.

Noteworthy was the fact that more adults (13.13%) perceived low nicotine cigarettes as being less harmful than conventional cigarettes, whereas only 4.23% perceived them as being more harmful, signalling the impact that misperceptions of nicotine have on the total risk perception of products.

In South Korea, where Heated Products and Vapour Products have been available, 3,713 tobacco and/or nicotine-using adults were surveyed, to gather insights on harm perceptions.^[5] Overall, around a quarter of respondents believed that Heated and Vapour Products (<28% and <24%, respectively) are less harmful than cigarettes. However, this belief is notably different between respondents who exclusively smoke and those who smoke cigarettes and use Heated Products and/or Vapour Products (Figure 2 and Figure 3, respectively).

(ii) Medical practitioner risk perception of THR products

Multiple leading public health and regulatory stakeholders have concluded that Smokeless Products, while not safe, are reduced-risk relative to smoking. Despite this, knowledge and subsequent risk perception of Smokeless Products is struggling to filter down to the ‘front line’ medical practitioners, who adult smokers rank as the most trustworthy source for information relating to risk (59.6% of 519 current adult smokers surveyed).^[6]

U.S. physicians have been provided with guidance relating to tobacco use through the U.S. Public Health Service-sponsored Clinical Practice Guideline 'Treating Tobacco Use and Dependence' publication.^[7] Updated in 2008, this guideline does not include any reference to e-cigarettes and/or other Smokeless Products.

Figure 2. Perceived harmfulness of Heated Products compared to cigarettes among adults who smoke cigarettes, Republic of Korea, June 2020 (%)

A 2018/9 U.S. cross-sectional survey of 2,058 physicians reported that more than three in four physicians had not used this Public Health Service-sponsored guideline (32.5% unaware of these guidelines, 40.6% aware but had not read the guidelines, and 7.3% had read the guidelines but did not use them).^[8] Of these 2,058 physicians, 70% reported being asked about e-cigarettes by their patients, with one in three physicians being asked within the past 30 days. When considering risk, most physicians (60.1%) endorsed the belief that “all forms of tobacco were equally harmful and that cessation from all tobacco use was the best approach.”

Figure 3. Perceived harmfulness of Vapour Products compared to cigarettes among adults who smoke cigarettes, Republic of Korea, June 2020 (%)

The remaining physicians (39.9%) endorsed the belief that cigarettes were the most dangerous form of tobacco and getting adult smokers to quit was the goal. However, only 22% of the surveyed physicians ever recommended e-cigarettes to adult smokers.

In Japan, where Heated Products is the most prevalent Smokeless Products, physician awareness of Smokeless Products was high (Heated Products, 76.7% and Vapour Products, 71.3%).^[9,10] Of the physicians who were aware of Heated Products (n=3,730), two in three were never smokers and a small number had ever used Heated Products (n=140). For physicians who had never smoked or used Heated Products, most (>50%) agreed with the statements “misguided assumption that [Heated Products] are less harmful than cigarettes” and “misguided assumption that [Heated Products] does not causing [sic] passive smoking.”

Agreement with these statements was lower for physicians who used Heated Products (<27%). All physicians had strong agreement with the statement “Lack of evidence regarding the long-term safety of [Heated Products]”. Overall, although most Japanese physicians were aware of Smokeless Products, disparity in knowledge regarding their relative risk compared to cigarettes may result in adult smokers receiving contrasting guidance and support with regards to quitting.

In contrast to U.S. and Japanese physician knowledge of Smokeless Products and their relative risk, the UK’s National Health Service (NHS) provides advice and support to adult smokers wanting to use e-cigarettes to quit smoking. In 2023, the UK Government pioneered a 'Swap to Stop' scheme with the ambition to encourage one million adult smokers to switch to e-cigarettes.^[11] The Government’s intention is to improve the health of the nation and cut smoking rates. This campaign highlights the progressive methodologies that countries such as the UK are adopting to persuade adult smokers to switch to lower risk profile tobacco and nicotine products.

Risk perception of nicotine by different stakeholder groups

(i) Adult risk perceptions of nicotine

In the survey of U.S. adults described above^[4], the respondents were asked to rank their perception of nicotine alone as well as nicotine in different product formats. Despite the public health guidance on nicotine, nearly two-thirds of adults perceive the nicotine in cigarettes to be what causes most of the cancer caused by smoking.

In different product formats adults ranked the risk of nicotine to be somewhat, very or extremely harmful, in cigarettes (89%) e-cigarettes (83%) and Nicotine Replacement Therapy (73%) (Table 2). This illustrates the need for the education of adults around nicotine risk, as otherwise we believe this will remain a barrier for adult smokers to switch to lower risk profile tobacco and nicotine products.

Table 2. Risk perceptions of nicotine amongst U.S. adults (%) ^[4]

Product Formats	Don’t Know	Not at all Harmful	Slightly Harmful	Somewhat Harmful	Very Harmful	Extremely Harmful
Nicotine	0.20	2.59	6.66	25.03	35.87	29.63
Nicotine in Cigarettes	0.29	2.40	7.88	28.20	33.81	27.41
Nicotine in EC	2.18	3.02	11.81	40.86	25.67	16.47
Nicotine in NRT	2.03	4.37	20.27	41.84	17.59	13.88

In the UK, a 2021 ASH Adult Survey of 1,679 adult smokers and Vapour Product consumers, reported that only 13.9% “had accurate perceptions believing that none or a very small amount of the risk of smoking were due to nicotine”.^[12]

Of the 1,679 respondents, >68% reported nicotine as being the source of risk in cigarette smoke to some degree (23.9% “under half the risk”, 17.3% “half the risk”, and 26.9% “much more than half the risk”). The remaining 18.1% of those surveyed did not know. This data further highlights the confusion that is faced by adults when considering the risks of nicotine.

(ii) Medical practitioner risk perception of nicotine

In a recent survey of 926 physicians in the U.S., the participants were asked to what extent they agree or disagree that nicotine on its own directly contributed to health effects (Table 3).^[13]

Table 3. Distribution of results to nicotine questions (%) ^[14]

Condition	Agree	Strongly Agree	Agree or strongly agree
COPD	10.2	67.3	77.5
CVD	11.9	78.2	90.1
Cancer	12.7	69.6	82.3

Similarly, a second published study surveyed 1,020 physicians and overall, most physicians “strongly agreed” that nicotine directly contributes to the development of cardiovascular disease (83.2%), COPD (80.9%), and cancer (80.5%).^[14]

A cityscape with a Swedish flag waving in the foreground

Linking THR risk perceptions to THR outcomes: the Swedish Experience

Utilising Sweden as the vanguard market for THR (lowest smoking incidence, equivalent per capita usage of tobacco and nicotine to EU, and lowest lung cancer fatalities), risk perceptions of THR products were assessed with Swedish adult smokers and Oral Nicotine Pouch consumers. This was then compared with THR perceptions from other markets that used similar products (Table 4).^[15]

In terms of target setting for national risk perception targets, one approach could be to achieve the favourable risk perception observed in Sweden of 74%, meaning that a national risk perception score of 100% would not necessarily be required to have a successful implementation of THR. Therefore, in Europe for example, new education programmes could be implemented in Denmark to improve risk perceptions from 31% to 74%; UK from 36% to 74% and Switzerland from 23% to 74%.

Table 4. THR Risk Perceptions: Oral Nicotine Pouches^[15]

THR Risk Perception^#

Country	Adult Smokers	Adult Oral Nicotine Pouch users	Adult Tobacco and Nicotine users	Oral Nicotine Pouches Incidence^##
Sweden	67%	71%	74%	55%
Denmark	23%	45%	31%	21%
UK	36%	36%	34%	8%
Switzerland	17%	42%	23%	8%

# Percentage of the cohort that believe Smokeless Products are safer than cigarettes

## Among Total Tobacco and Nicotine Market

Overview of THR perceptions in key Smokeless Product markets

A summary of Smokeless Product penetration and THR risk perception for all three categories in selected markets for each category is summarised in Table 5.^[15] Heated Products have a market penetration of 21-45% and with an average favourable THR score of 55%. Vapour Products have a market penetration of 19-57% and with an average favourable THR score of 52%. Oral Nicotine Pouches have a market penetration of 2-55% and with an average favourable THR score of 50%. Improving favourable THR risk perceptions would go a long way to improving the adoption of Smokeless Products, facilitating the migration of adult smokers to lower risk products.

An assortment of vaping devices and nicotine pouches

Table 5. THR perceptions and market penetration: a category view^[15]

Heated products

Market	Heated Products Incidence^{^} (%)	Favourable THR perceptions^{^^} (%)
Japan	45	70
Italy	31	50
Poland	21	50
Korea	32	50
Average	32	55

Vapour products

Market	Vapour Products Incidence (%)	Favourable THR perceptions^{^^} (%)
Canada	38	53
UK	57	64
France	31	51
Germany	19	39
Average	36	52

Oral Nicotine Pouches

Market	Oral Nicotine Pouches Incidence^{^} (%)	Favourable THR perceptions^{^^} (%)
Sweden	55	74
Denmark	21	31
Switzerland	8	23
Pakistan	2	71
Average	22	50

^ Percentage of the cohort that believe THR products are safer than cigarettes

^^ Among Total Tobacco and Nicotine Market

Advancing forward

The key to making progress in correcting misperceptions on the risk profile of THR products and nicotine in general comes down to improving education. There is an urgent need for clear, informed, science backed communications from key stakeholder groups. While important publications supporting THR (see Big Question 6, Page 64) are becoming more prominent across the globe, more must be done to amplify these messages and ensure accurate information gets into the hands of the front-line medical community.

*Based on the weight of evidence and assuming a complete switch from cigarette smoking. These products are not risk free and are addictive.

†Our products as sold in the U.S., including Vuse, Velo, Grizzly, Kodiak, and Camel Snus, are subject to FDA regulation and no reduced-risk claims will be made as to these products without agency clearance.

Sources

[1] Paek, H.J., and Hove, T., Risk perceptions and risk characteristics. In Oxford research encyclopedia of communication, 2017. DOI: 10.1093/acrefore/9780190228613.013.283

[2] Action on Smoking and Health (ASH), Use of e-cigarettes (vapes) among adults in Great Britain. 2023. Available at: https://ash.org.uk/uploads/Use-of-e-cigarettes-among-adults-in-Great-Britain-2023.pdf

[3] Toll, B.A., et al., Nicotine e-cigarettes: considerations for healthcare providers. Nat Med, 2024. 30: p. 1513–1514. DOI: 10.1038/s41591-024-02926-7

[4] Denlinger-Apte, R.L., et al., Risk perceptions of low nicotine cigarettes and alternative nicotine products across priority smoking populations. Int J Environ Res Public Health, 2021. 18(10): p. 5311. DOI: 10.3390/ijerph18105311

[5] Goulette, M.R., et al., Perceptions of harmfulness of heated tobacco and nicotine vaping products compared to cigarettes, and the association of advertising exposure on harm perceptions among adults who smoke in South Korea: Cross-sectional findings from the 2020 ITC Korea Survey. Tob Induc Dis, 2023. 21:121. DOI: 10.18332/tid/170252

[6] Wackowski, O.A., et al., Smokers' sources of e-cigarette awareness and risk information. Prev Med Rep, 2015. 2: p. 906-910. DOI: 10.1016/j.pmedr.2015.10.006

[7] Tobacco Use and Dependence Guideline Panel, Treating Tobacco Use and Dependence: 2008 Update. US Department of Health and Human Service: Atlanta, GA, USA, 2008. Available at: https://www.ncbi.nlm.nih.gov/books/NBK63952/ (Accessed: 30 July 2024)

[8] Delnevo, C.D., et al., Communication Between US Physicians and Patients Regarding Electronic Cigarette Use. JAMA Netw Open, 2022. 5(4): p. e226692. DOI: 10.1001/jamanetworkopen.2022.6692

[9] Otsuka Y., et al., Awareness, Attitudes, and Concerns Regarding Heated Tobacco Products Among Physicians in Japan. J Epidemiol, 2023. 33(9): p. 441-449. DOI: 10.2188/jea.JE20210470

[10] Otsuka, Y., et al., Prevalence, knowledge, and concerns regarding the use of heated tobacco products and electronic cigarettes among young Japanese physicians. Tob Induc Dis, 2024. 22. DOI: 10.18332/tid/178508

[11] Department of Health and Social Care, Press release: Smokers urged to swap cigarettes for vapes in world first scheme’ Press Release. Gov.UK,

2023. Available at: https://www.gov.uk/government/news/smokers-urged-to-swap-cigarettes-for-vapes-in-world-first-scheme (Accessed: 30 July 2024)

[12] McNeill, A., et al., Nicotine vaping in England: an evidence update including health risks and perceptions. Office for Health Improvement and Disparities, 2022. Available at: https://assets.publishing.service.gov.uk/media/633469fc8fa8f5066d28e1a2/Nicotine-vaping-in-England-2022-report.pdf

[13] Bover Manderski, M.T., et al., Persistent misperceptions about nicotine among US physicians: results from a randomized survey experiment. Int J Environ Res Public Health, 2021. 18(14): p. 7713. DOI: 10.3390/ijerph18147713

[14] Steinberg, M.B., et al., Nicotine risk misperception among US physicians. Journal of General Internal Medicine, 2021. 36(12): p. 3888-3890. DOI: 10.1007/s11606-020-06172-8

[15] BAT, THR Perceptions Presentation, Unpublished, 1 June 2024