Brown, J

Jackson, SE

Shahab, L

Tattan-Birch, H

English

UCL Discovery

Research Letter | Public HealthAssociation of the US Outbreak of Vaping-Associated Lung InjuryWith Perceived Harm of e-Cigarettes Compared With CigarettesHarry Tattan-Birch, MSc; Jamie Brown, PhD; Lion Shahab, PhD; Sarah E Jackson, PhDIntroductionThe US Food and Drug Administration acknowledges that nicotine and tobacco products exist on acontinuum of risk, with e-cigarettes likely to be less harmful than combustible cigarettes because oftheir lower production of toxicants and carcinogens.1,2 However, many smokers in England and theUS believe that e-cigarettes are at least as harmful to health as combustible cigarettes.2,3 Thesemisperceptions likely dissuade smokers who are unable or unwilling to stop using nicotine fromswitching to e-cigarettes, which may have a detrimental effect on population health. The recent USoutbreak 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 sometetrahydrocannabinol vaping devices.5 However, news reports often failed to distinguishtetrahydrocannabinol devices from standard nicotine-based e-cigarettes, which may have increasedconfusion about the relative harms of different nicotine products. This study examined the extentto which perceptions of the harm of e-cigarettes compared with combustible cigarettes changedamong smokers after the EVALI outbreak.MethodsThis survey study used data from the Smoking Toolkit Study, a monthly cross-sectional nationallyrepresentative survey of adults (aged >16 years) in England. Oral informed consent was obtainedfrom participants, and ethical approval was granted by the University College London EthicsCommittee. The study followed American Association for Public Opinion Research (AAPOR) reportingguideline.Current smokers were asked, “Compared to regular cigarettes, do you think electroniccigarettes are more, less, or equally harmful to health?” They could also respond, “don’t know.” Self-reported sex, age, socioeconomic status, race/ethnicity, and current e-cigarette use were alsomeasured. The analysis plan was preregistered.The majority of EVALI hospitalizations were between mid-August and mid-September 2019,4and internet searches for vaping and vaping death peaked mid-September.6 Thus, we comparedharm perceptions in 2019 before the EVALI outbreak (January to July 2019) with those after theoutbreak (August to December 2019). Log-binomial regression was used to assess the associationbetween timing of the outbreak and the proportion of smokers who believed that e-cigarettes wereless harmful than cigarettes before and after adjusting for sociodemographic factors and e-cigaretteuse. In secondary analyses, we calculated associations between timing of the outbreak and theproportion 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 bestatistically significant.ResultsOf the 3215 current smokers surveyed in 2019, 1833 were interviewed before the outbreak (849[46.3%] women; mean [SD] age, 43.5 [17.6] years) and 1382 were interviewed after (604 [43.7%]Author affiliations and article information arelisted at the end of this article.Open Access. This is an open access article distributed under the terms of the CC-BY License.JAMA Network Open. 2020;3(6):e206981. doi:10.1001/jamanetworkopen.2020.6981 (Reprinted) June 15, 2020 1/3Downloaded From: https://jamanetwork.com/ by a University College London User  on 06/23/2020women; mean [SD] age, 43.0 [17.8] years). The proportion who perceived e-cigarettes as less harmfulthan combustible cigarettes decreased significantly from 37.0% (n = 678) before to 30.9% (n = 427)after the outbreak (risk ratio [RR], 0.83; 95% CI, 0.76-0.92; P < .001), and significantly fewersmokers reported not knowing which product was more harmful (191 [10.4%] vs 112 [8.1%]; RR, 0.78;95% CI, 0.63-0.98; P = .03). Conversely, there were significant increases in the proportion ofindividuals who perceived e-cigarettes as equally harmful (731 [39.9%] vs 605 [43.8%]; RR, 1.10;95% CI, 1.01-1.19; P = .01) or more harmful (233 [12.7%] vs 238 [17.2%]; RR, 1.36; 95% CI, 1.15-1.61;P < .001) than cigarettes. All significant differences remained after adjustment for covariates (Table).The Figure shows harm perceptions among smokers from 2016 through 2019. In the finalquarter of 2019, the percentage of individuals who perceived e-cigarette use as less harmful thancigarette smoking decreased to the lowest point recorded (239 [29.5%]; 95% CI, 26.5%-32.8%), andthe percentage perceiving it as more harmful peaked (155 [19.2%]; 95% CI, 16.6%-22.0%).DiscussionAfter the US outbreak of vaping-associated lung injury, views on e-cigarettes among smokers in En-gland deteriorated. The proportion perceiving e-cigarette use as less harmful than cigarette smokingdecreased, 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. Itis possible that people who had quit smoking cigarettes through vaping might now return tosmoking, and cigarette smokers might be deterred from using e-cigarette devices to help them quit.Table. Harm Perceptions of e-Cigarettes Compared With Cigarettes Among Current Smokers in England Before (January to July 2019)and After (August to December 2019) the Outbreak of Vaping-Associated Lung InjuryHarm perceptionSmokers, No. (%) [95% CI]Unadjusted risk ratio (95%CI) P value Adjusted risk ratio (95%CI)a P valueBefore outbreak (n = 1833) After outbreak (n = 1382)Less harmful 678 (37.0) [34.7-39.3] 427 (30.9) [28.5-33.4] 0.83 (0.76-0.92) <.001 0.81 (0.74-0.90) <.001Equally harmful 731 (39.9) [37.7-42.2] 605 (43.8) [41.2-46.4] 1.10 (1.01-1.19) .01 1.09 (1.01-1.18) .02More harmful 233 (12.7) [11.2-14.3] 238 (17.2) [15.3-19.3] 1.36 (1.15-1.61) <.001 1.38 (1.17-1.62) <.001Don’t know 191 (10.4) [9.1-11.8] 112 (8.1) [6.8-9.7] 0.78 (0.63-0.98) .03 0.78 (0.62-0.97) .03a Adjusted analyses included sex, age, social grade, race/ethnicity, and e-cigarette use as covariates.Figure. Perceived Harm of e-Cigarettes Compared With Cigarettes Among Smokers in England From 2016 to 201950403020100March SeptemberJune December March SeptemberJune December March SeptemberJune December March SeptemberJune DecemberCurrent smokers, %Time2016 2017 2018 2019Less harmfulEqually harmfulMore harmfulDon't knowA total of 13 781 current smokers were surveyed (approximately 860 per quarter). Solid lines represent means; shaded areas, 95% CIs; and dotted vertical line, the peak of thevaping-associated lung injury outbreak.JAMA Network Open | Public Health The US Outbreak of Vaping-Associated Lung Injury and Perceived Harm of e-Cigarettes vs CigarettesJAMA Network Open. 2020;3(6):e206981. doi:10.1001/jamanetworkopen.2020.6981 (Reprinted) June 15, 2020 2/3Downloaded From: https://jamanetwork.com/ by a University College London User  on 06/23/2020On the other hand, young people who have never smoked may be dissuaded from ever tryinge-cigarettes. A limitation of this study is that only smokers in England were surveyed. The associationbetween EVALI and harm perceptions may differ across countries. In the US, where the outbreakoccurred and precipitated fierce political debate, there may have been an even greater change.These results highlight the importance of clear communication from public health bodies about therelative harm of different nicotine products. Future research should explore how these changingperceptions affect smoking and e-cigarette use prevalence in the US and beyond.ARTICLE INFORMATIONAccepted for Publication: March 31, 2020.Published: June 15, 2020. doi:10.1001/jamanetworkopen.2020.6981Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Tattan-BirchH et al. JAMA Network Open.Corresponding Author: Harry Tattan-Birch, MSc, Institute of Epidemiology and Health Care, University CollegeLondon, 1-19 Torrington Place, Fitzrovia, London WC1E 7H, UK (h.tattan-birch@ucl.ac.uk).Author Affiliations: Institute of Epidemiology and Health Care, University College London, London, UK (Tattan-Birch, Brown, Shahab, Jackson); SPECTRUM Research Consortium, UK (Tattan-Birch, Brown, Shahab, Jackson).Author Contributions: Mr Tattan-Birch had full access to all of the data in the study and takes responsibility for theintegrity of the data and the accuracy of the data analysis.Concept and design: Tattan-Birch, Brown, Jackson.Acquisition, analysis, or interpretation of data: Tattan-Birch, Brown, Shahab.Drafting of the manuscript: Tattan-Birch.Critical revision of the manuscript for important intellectual content: Brown, Shahab, Jackson.Statistical analysis: Tattan-Birch.Obtained funding: Brown, Jackson.Supervision: Brown, Shahab, Jackson.Conflict of Interest Disclosures: Dr Brown reported receiving unrestricted research funding from Pfizer. DrShahab reported receiving grants from Pfizer and personal fees from Johnson&Johnson outside the submittedwork. No other disclosures were reported.Funding/Support: The Smoking Toolkit Study is funded by C1417/A22962 from Cancer Research UK. Mr Tattan-Birch received fellowship funding from Public Health England during the conduct of the study.Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection,management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; anddecision to submit the manuscript for publication.REFERENCES1. US Food and Drug Administration. FDA announces comprehensive regulatory plan to shift trajectory of tobacco-related disease, death. 2018. Accessed November 22, 2019. https://www.fda.gov/news-events/press-announcements/fda-announces-comprehensive-regulatory-plan-shift-trajectory-tobacco-related-disease-death2. Mcneill A, Brose LS, Calder R, Bauld L, Robson D. Evidence review of e-cigarettes and heated tobacco products2018: a report commissioned by Public Health England. Public Health England; 2018.3. Nyman AL, Huang J, Weaver SR, Eriksen MP. Perceived comparative harm of cigarettes and electronic nicotinedelivery systems. JAMA Netw Open. 2019;2(11):e1915680. doi:10.1001/jamanetworkopen.2019.156804. Centers for Disease Control and Prevention. Outbreak of lung injury associated with the use of e-cigarette, orvaping, products. 2019. Accessed November 22, 2019. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-outbreak-information5. Nyakutsikwa B, Britton J, Bogdanovica I, Langley T. Vitamin E acetate is not present in licit e-cigarette productsavailable on the UK market. Addiction. January 2020:add.14920. doi:10.1111/add.149206. Google. Interest in “vaping” and “vaping deaths” from 2018 to 2019. Google Trends. Published 2019. AccessedApril 30, 2020. https://trends.google.com/trends/explore/TIMESERIES/1574436000?hl=en-GB&tz=0&geo=GB&q=vaping,vaping+deaths&sni=3JAMA Network Open | Public Health The US Outbreak of Vaping-Associated Lung Injury and Perceived Harm of e-Cigarettes vs CigarettesJAMA Network Open. 2020;3(6):e206981. doi:10.1001/jamanetworkopen.2020.6981 (Reprinted) June 15, 2020 3/3Downloaded From: https://jamanetwork.com/ by a University College London User  on 06/23/2020

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

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

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