healthmedicinet

Combusted tobacco products inhaled into the lungs are the greatest cause of health-related
harms resulting from use of tobacco products 1], 2]. It is also acknowledged by the United States Food and Drug Administration (FDA)
3] and others 1], 4], 5] that there is evidence of a continuum of risk, with cigarettes constituting the most
harmful tobacco/nicotine product and with nicotine replacement products, some smokeless
tobacco products, and electronic cigarettes involving relatively low levels of risk
3], 6]. Though not welcomed by all tobacco control authorities (e.g., 7]), there has been support for including harm reduction strategies as one of the many
traditional strategies for reducing the death and disability caused by tobacco use,
particularly cigarette smoking (e.g., 2], 8]–10]). Tobacco harm reduction focuses on encouraging the use of less dangerous forms of
tobacco/nicotine by those who prefer not to abstain from all tobacco/nicotine products
(e.g., 4]).

The FDA through its Center for Tobacco Products intends to invest in public education
campaigns to “help educate the public–especially youth–about the dangers of regulated
tobacco products” 11]. Coupled with a proliferation in the marketplace of “alternative” tobacco products
(e-cigarettes, hookah, smokeless formulations) that differ in degree of risk 6] and the influence of perceptions of risk on product usage 12], it could be important for the FDA to help inform the public of the differential
risks of the use of various tobacco/nicotine products 13].

Given the scientific consensus that cigarettes are the most deadly form of tobacco
use, the public has a right to a clear understanding of this fact 14]–16] and efforts should be made to impart an understanding of the differential health
risks for various tobacco/nicotine products 13]. In order to accomplish this goal, though, we need to know how the public’s understanding
matches current scientific knowledge about relative harms. Given that information
about risk is used to make behavioral decisions 12], such knowledge about public perceptions of risks will help us better understand
choices that individuals make about tobacco product use. Moreover, given the ethical
obligation to communicate accurate information about harm reduction 14] and the FDA’s plans to educate the public about tobacco, understanding where the
public is at now with respect to risk beliefs about tobacco products is an important
step toward designing effective programming.

To advance these goals, we examined public perceptions of the relative risk of different
tobacco formulations using data from the National Cancer Institute’s Health Information
National Trend Survey (HINTS) 4 Cycle 2 17]. The survey included questions about the risks, relative to “traditional” cigarettes,
of different types of cigarettes, smokeless tobacco products, and electronic cigarettes.
Tan and Bigman 18] have reported results for e-cigarettes from this survey but did not explore interrelationships
across the multiple tobacco harm reduction questions. We used these questions to examine
the current distribution of relative risk knowledge and, based on current epidemiological
understanding (reviewed below), to determine how public perceptions match to the scientific
evidence.

Evidence for harm reduction modalities

The alternative tobacco product modalities addressed in the HINTS survey can be organized
according to the clarity of what the correct, evidence-based answer should be regarding
their riskiness relative to smoking “traditional” cigarettes. The question (see “Methods”
for the questions) asking whether some cigarettes are less harmful than others is
correctly answered, “no.” The argument for cigarettes being equal in risk is made
here 19]. A key principle for understanding this issue is to understand the problem of compensatory
smoking, in which smoking behavior can cause smokers to get what they desire from
any brand of conventional cigarette based on how they puff on the cigarette (e.g.,
20]).

Second, the question of whether some smokeless tobacco products are less harmful than
cigarettes is correctly answered, “yes.” While not safe, some smokeless tobacco formulations
are significantly less dangerous to users than cigarettes 21]. One of the most thorough reviews was done for the European Union 22] and concluded, referring to major chronic diseases that “. . . . in relation to the
risks of the above major smoking-related diseases, and with the exception of pregnancy,
[smokeless tobacco products] are clearly less hazardous, and in relation to respiratory
and cardiovascular disease substantially less hazardous, than cigarette smoking.”
(p. 114–115). For cardiovascular disease, the risk reduction was judged as “at least
50 %,” for oral and gastrointestinal cancer “probably also at least 50 %,” and for
respiratory disease “close to 100 %.”

Finally, for electronic cigarettes (e-cigarettes, vaping), the question asked if they
were more or less harmful than cigarettes; the best evidence-based opinion at the
present time would be, not safe, but much lower in risk 23], 24].

Public perceptions and patterns of responses on harm reduction

We examined descriptive statistics on the proportions of individuals holding harm
reduction beliefs about each formulation, as well as the “match” of the public’s beliefs
and the evidence-based answers reviewed above. In addition to assessing beliefs question
by question, the coherence or consistency of accurate beliefs across questions is
important, because it could indicate a broader understanding of the underlying etiological
principles involved.