Perceptions of e-cigarette harm among cancer survivors: Findings from a nationally representative survey

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Introduction

Electronic cigarettes (e-cigarettes) are gaining in popularity as an alternative to conventional cigarettes even though their health implications are unclear 123 . Although the U.S. Food and Drug Administration (FDA) endorses that there are health risks associated with its use, the incidence of e-cigarette use has been increasing in nearly all populations including adolescents, adults, smokers and non-smokers, as well as cancer survivors [34] . Among cancer survivors specifically, e-cigarette use has risen from 8.5% in 2014 to 10.7% in 2017, [9] while up to 26% of newly diagnosed cancer survivors continue to use e-cigarettes. [39] Given the increasing use of e-cigarettes, there is pressing need to understand reasons for adoption in this vulnerable population. Perception of a product’s harm has been shown to influence consumer behavior [5] . Therefore, we postulate that increasing use among cancer survivors may be driven by underappreciation of the harms and health implications of e-cigarette use.

Cancer survivors have different perceptions of risk compared to non-cancer participants and this plays a critical role in decisions to use tobacco and potentially e-cigarettes 678 . The increase in e-cigarette use among cancer survivors may reflect a perception that e-cigarettes are low risk even though e-cigarette use has been linked to the potential of several smoking related malignancies 91011 . Specifically, the rise in their use may reflect, in part, a perceived harm reduction approach to smoking cessation [12] . This strategy aims to curb combustible cigarette smoking by encouraging smokers to switch to potentially lower-risk tobacco products such as e-cigarettes. However, this approach appears to have limited success and may potentially promote dual use 13141516 . Several cancer organizations including the National Comprehensive Cancer Network (NCCN), [17] American Cancer Society (ACS), [18] American Association for Cancer Research (AACR), [19] and the American Society of Clinical Oncologists (ASCO) [19] all have issued guidelines or statements that recognize the potential for e-cigarettes to alter existing smoking behaviors, as well as the lack of definitive data regarding associated benefits and harms. However, to date none of these organizations endorse e-cigarette use and the impact of their use continues to be an important question for cancer providers [1719] . Understanding the perceived harm of e-cigarette use among cancer survivors may inform the observed shifts in e-cigarette patterns of use along with public health planning.

There is a paucity of contemporary nationally representative studies evaluating perceptions of e-cigarette harms among cancer survivors. The primary objective of this study was to assess perceived harmfulness of e-cigarettes relative to conventional cigarettes among cancer survivors compared to non-cancer respondents using a nationally representative survey of U.S. adults. We determined factors associated with the perception that e-cigarettes are as much or more harmful than conventional cigarettes. As a secondary study objective, we sought to assess whether this perceived relative harm has changed over time. As late adolescents and young adults have the highest prevalence of using e-cigarettes, we included a sub-analysis of this group. Additionally, smoking linked cardiopulmonary disease may impact perceived e-cigarette harm and was therefore included in our analysis.