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‘The lesser devil you don’t know’: a qualitative study of smokers’ responses to messages communicating comparative risk of electronic and combusted cigarettes
  1. Daniel Owusu1,
  2. Rachel Lawley1,
  3. Bo Yang1,
  4. Katherine Henderson1,
  5. Brittaney Bethea2,
  6. Christopher LaRose3,
  7. Sam Stallworth3,
  8. Lucy Popova1
  1. 1 School of Public Health, Georgia State University, Atlanta, Georgia, USA
  2. 2 Department of Communication, Georgia State University, Atlanta, Georgia, USA
  3. 3 John Snow, Inc, Atlanta, Georgia, USA
  1. Correspondence to Dr Lucy Popova, School of Public Health, Georgia State University, Atlanta, GA 30302, USA; lpopova1{at}


Introduction Communicating to smokers that e-cigarettes deliver lower levels of harmful chemicals than combusted cigarettes is a challenging issue. This study qualitatively explored smokers’ interpretations of messages communicating the risk of e-cigarettes relative to cigarettes (comparative risk messages).

Method We developed 12 print comparative risk messages and evaluated them in 12 focus groups with 72 adult smokers (18+ years old) in Atlanta, Georgia.

Results Participants interpreted uncertainty about health effects of e-cigarettes as an indicator of significant unknown risks, which some believed to be potentially more severe than the known effects of cigarettes (such as cancer and heart disease). Also, participants were sceptical about the lower risk claims. Some participants misinterpreted what ‘switching completely’ or ‘switching 100% of the time’ means, perceiving switching from e-cigarettes to combusted cigarettes as comparable with the use of both products. When chemicals in e-cigarettes were mentioned (eg, nicotine or formaldehyde), participants viewed e-cigarettes as very harmful and had difficulty reconciling this belief with the reduced risk claim. Comparative risk messages emphasising smoking risks were perceived as effective. Participants also appreciated being given an option to switch if they cannot quit. Participants suggested the inclusion of more facts and statistics and a credible message source (eg, public health agencies) to increase message effectiveness.

Conclusion Comparative risk messages may be more acceptable to smokers if they show direct comparisons of the number of toxic chemicals in cigarettes and e-cigarettes, are attributed to a credible source(s), and emphasise smoking risks.

  • comparative risk
  • modified risk
  • e-cigarettes
  • e-cigarette messages

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  • Contributors DO prepared the first draft of the manuscript. CL and SS conducted participant recruitment and data collection with technical support from DO, RL and LP. CL and SS moderated the focus groups. DO, RL, BY, KH, BB and LP developed the codebook and wrote memos. KH and BB coded the transcripts. LP conceptualised and supervised the study. All participants contributed to the interpretation of the results and revision of the paper.

  • Funding Research reported in this publication was supported by the National Institute of Drug Abuse of the National Institutes of Health and Food and Drug Administration Center for Tobacco Products (P50DA036128) and the National Cancer Institute of the National Institutes of Health and Food and Drug Administration Center for Tobacco Products (R00CA187460). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Food and Drug Administration.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Georgia State University Institutional Review Board.

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

  • Data sharing statement Data are available upon reasonable request to the corresponding author.