Association of the US Outbreak of Vaping-Associated Lung Injury With Perceived Harm of e-Cigarettes Compared With Cigarettes

This survey study assesses the perceptions of e-cigarettes among current smokers in England before and after the US outbreak of vaping-associated lung injury.


Introduction
The US Food and Drug Administration acknowledges that nicotine and tobacco products exist on a continuum of risk, with e-cigarettes likely to be less harmful than combustible cigarettes because of their lower production of toxicants and carcinogens. 1,2 However, many smokers in England and the US believe that e-cigarettes are at least as harmful to health as combustible cigarettes. 2,3 These misperceptions likely dissuade smokers who are unable or unwilling to stop using nicotine from switching to e-cigarettes, which may have a detrimental effect on population health. The recent US outbreak of vaping-associated lung injury (EVALI) 4 received extended news coverage worldwide.
Most cases were associated with inhalation of vitamin E acetate, an additive found in some tetrahydrocannabinol vaping devices. 5 However, news reports often failed to distinguish tetrahydrocannabinol devices from standard nicotine-based e-cigarettes, which may have increased confusion about the relative harms of different nicotine products. This study examined the extent to which perceptions of the harm of e-cigarettes compared with combustible cigarettes changed among smokers after the EVALI outbreak.

Methods
This survey study used data from the Smoking Toolkit Study, a monthly cross-sectional nationally representative survey of adults (aged >16 years) in England. Oral informed consent was obtained from participants, and ethical approval was granted by the University College London Ethics Committee. The study followed American Association for Public Opinion Research (AAPOR) reporting guideline.
Current smokers were asked, "Compared to regular cigarettes, do you think electronic cigarettes are more, less, or equally harmful to health?" They could also respond, "don't know." Selfreported sex, age, socioeconomic status, race/ethnicity, and current e-cigarette use were also measured. The analysis plan was preregistered.
The majority of EVALI hospitalizations were between mid-August and mid-September 2019, 4 and internet searches for vaping and vaping death peaked mid-September. 6 Thus, we compared harm perceptions in 2019 before the EVALI outbreak (January to July 2019) with those after the outbreak (August to December 2019). Log-binomial regression was used to assess the association between timing of the outbreak and the proportion of smokers who believed that e-cigarettes were less harmful than cigarettes before and after adjusting for sociodemographic factors and e-cigarette use. In secondary analyses, we calculated associations between timing of the outbreak and the proportion of people reporting each of the other responses. Analyses were conducted using R, version 3.5.3 (R Foundation for Statistical Computing). A 1-sided P < .05 was considered to be statistically significant. P < .001) than cigarettes. All significant differences remained after adjustment for covariates (Table).

Results
The

Discussion
After the US outbreak of vaping-associated lung injury, views on e-cigarettes among smokers in England deteriorated. The proportion perceiving e-cigarette use as less harmful than cigarette smoking decreased, and the proportion perceiving e-cigarette use as more harmful increased by over one-third.
The effects that these worsened harm perceptions will have on population health is unclear. It is possible that people who had quit smoking cigarettes through vaping might now return to smoking, and cigarette smokers might be deterred from using e-cigarette devices to help them quit.