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How do consumers perceive differences in risk across nicotine products? A review of relative risk perceptions across smokeless tobacco, e-cigarettes, nicotine replacement therapy and combustible cigarettes
  1. Christine D Czoli1,
  2. Geoffrey T Fong1,2,3,
  3. Darren Mays4,
  4. David Hammond1
  1. 1School of Public Health & Health Systems, University of Waterloo, Waterloo, Ontario, Canada
  2. 2Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada
  3. 3Ontario Institute for Cancer Research
  4. 4Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington District of Columbia, USA
  1. Correspondence to Dr David Hammond, School of Public Health & Health Systems, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, Canada N2L 3G1; dhammond{at}


Objective To systematically review the literature regarding relative risk perceptions (RRPs) across non-combustible nicotine products.

Data sources MEDLINE and PsycINFO databases were searched for articles published up to October 2014.

Study selection Of the 5266 records identified, articles not published in English that did not quantitatively assess RRPs across categories of non-combustible nicotine products were excluded, yielding 55 records.

Data extraction One reviewer extracted measures and findings of RRPs for product comparisons of smokeless tobacco (SLT), e-cigarettes (ECs) and nicotine replacement therapy (NRT) to one another, and to combustible cigarettes (CCs).

Data synthesis A total of 157 samples from 54 studies were included in the analyses. The accuracy of RRPs differed based on the products being compared: although the accuracy of RRPs was variable across studies, substantial proportions of respondents reported inaccurate beliefs about the relative harmfulness of SLT versus CCs, as well as of ECs versus NRT. In addition, in most studies, respondents did not know the relative harmfulness of SLT versus NRT. In contrast, respondents in many studies correctly perceived NRT and ECs as less harmful than CCs. Cigarette smokers and users of non-combustible nicotine products tended to correctly perceive the relative harmfulness of products more often than non-users. Measures used to assess RRPs varied across studies, with different approaches characterised by certain strengths and limitations.

Conclusions The highly variable and context-specific nature of non-combustible nicotine product RRPs have direct implications for researchers and present several challenges for policymakers working with modified risk products, including issues of measurement, health risk communication and behaviour change.

  • Nicotine
  • Non-cigarette tobacco products
  • Electronic nicotine delivery devices
  • Public policy

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  • Twitter Follow Christine Czoli at @CCzoli

  • Contributors CDC and DH conceptualised the study objectives and analytic approach. CDC conducted the literature review, analysed the data and drafted the manuscript. GTF, DM and DH provided substantial contributions to the writing and finalising of the manuscript. All approved the final version.

  • Funding This research was supported by Canadian Institutes of Health Research (CIHR) Vanier Canada Graduate Scholarship (Czoli), as well as CIHR New Investigator Award (Hammond) and CIHR PHAC Chair in Applied Public Health (Hammond). This research was also supported in part by National Institutes of Health (NIH) and the Food and Drug Administration (FDA) Center for Tobacco Products under NIH grant number CA172217 (Mays). The study sponsors had no role in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the abstract for publication. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the FDA.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.