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Original research
‘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}gsu.edu

Abstract

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

https://doi.org/10.1136/tobaccocontrol-2018-054883

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    Introduction

    Electronic cigarettes (e-cigarettes) contain toxic chemicals and may negatively impact the cardiovascular and respiratory systems.1–5 However, the levels of toxic chemicals in e-cigarettes are lower than the levels in combusted cigarettes.4 6 Hence, smokers who are not willing to give up smoking may reduce their health risks from tobacco use if they switch completely to e-cigarettes.7–9 This information needs to be communicated to such smokers, but presenting e-cigarettes as less harmful may lead to unintended consequences, such as dual use of cigarettes and e-cigarettes by current smokers and switching by smokers who would have otherwise quit smoking.10 11

    In the USA, the Food and Drug Administration (FDA) regulates e-cigarettes as tobacco products.12 For tobacco products that may present less health risks to consumers than the currently sold tobacco products, FDA allows tobacco companies to apply for permission to market the products as modified risk tobacco products (MRTP) and make comparative risk (lower risk) claims.13 As of March 2019, FDA has received several MRTP applications for non-combusted tobacco products such as Camel Snus and IQOS heated tobacco product, and an MRTP application for e-cigarettes may occur soon.14–16 Therefore, there is a need to identify effective comparative risk messages about e-cigarettes (messages communicating the risks of e-cigarettes relative to cigarettes) that motivate switching among smokers who are unwilling to quit while preventing or minimising unintended consequences.

    Recently, researchers have begun evaluating messages about comparative risks of electronic and combusted cigarettes.17–24 Quantitative studies of comparative risk messages have reported mixed findings. While some studies found that comparative risk messages may encourage smoking cessation,20 24 reduce perceived risk of e-cigarettes relative to cigarettes, and may not change dual use intentions,21 24 others found that comparative risk messages may increase dual use intentions among smokers.21 22 Given the mixed findings and the challenges of developing comparative risk communication about e-cigarettes, there is a need for an in-depth understanding of the impacts and important aspects of comparative risk messages. Qualitative studies are particularly good at providing nuanced examination of reactions to messages. However, qualitative studies of comparative risk messages are scarce. To the best of our knowledge, only one study has qualitatively evaluated two versions of comparative risk messages.23 This study reported that while some participants believed the messages were accurate, most were sceptical about the messages.23 Additional qualitative studies are needed to evaluate comparative risk messages to gain a deeper understanding of how smokers interpret these messages. To fill this gap, we developed 12 messages about comparative risks of e-cigarettes and combusted cigarettes and qualitatively evaluated them in focus groups with adult current smokers in Atlanta, Georgia. This study responds to the US FDA’s call for scientific investigation on how to communicate about novel tobacco products.

    Methods

    Message development

    The development of the messages was a collaborative work between tobacco control and health communication experts from Georgia State University (GSU) and John Snow Inc (JSI), a public health consulting firm. A comprehensive literature review was conducted for information on perceptions, knowledge and motivation for use of e-cigarettes. This was followed by an environmental scan for existing campaigns about e-cigarettes in the USA. Based on the information obtained from these reviews, and from the team’s expertise, 12 comparative risk messages were developed (see online supplement A). Messages featured various information such as what we do and do not know about e-cigarettes, health effects of cigarettes and e-cigarettes, toxic chemicals, nicotine and taking control. Messages differed in their use of visual and textual elements, light and dark colours, use of images and emphasis on the lower risks of e-cigarettes or on the higher risks of combusted cigarettes.

    Participants

    Eligible participants were adults who had smoked at least 100 cigarettes in their life time and were currently smoking every day or some days (current smokers) or had quit smoking within the past 2 years (recent quitters). Both online (Craigslist and Facebook advertisements) and offline (flyers placed in bars, coffee shops, convenience stores, etc) recruitment strategies were used to invite potential participants. All invited persons completed an online screener that assessed age and tobacco use status and gathered additional demographic information. Using the iterative approach, recruitment continued until saturation was reached in the focus group discussions. In total, 72 adult current smokers participated in the study. Participants were grouped into committed smokers (no intention to quit in the next 6 months, n=22, 4 focus groups), contemplating smokers (thinking about quitting in the next 6 months, n=30, 4 focus groups), and transitioning smokers (currently trying to quit, n=22, 4 focus groups). Each participant was compensated with $50 for their time and travel cost.

    Focus group discussions

    Twelve focus groups were conducted in-person 18 May–8 June 2017. Focus groups were held in a large conference room within JSI’s Atlanta, Georgia, office. This location had close proximity to public transportation and onsite parking. The conference room was equipped with teleconference stations and network-linked LED monitors for the presentation of the messages, and remote connectivity of computer videoconferencing, secured via a virtual private network, was also available for GSU and JSI staff to observe groups from remote locations.

    A series of initial questions probed perceptions of nicotine delivery in electronic cigarettes when compared with regular cigarettes and perceived health risks and benefits of e-cigarettes versus regular cigarettes, followed by questions about participants’ attempts to quit tobacco products. After the initial questions, participants were shown the messages followed by a discussion of participants’ perceptions of them. (The detailed questions are provided in the Moderator Guide in online supplement B.) Messages were projected on a large screen, and an experienced moderator led the discussions using a prepared moderator guide. Each focus group saw eight messages selected at random from the 12 messages. Messages were presented and discussed one at a time, that is, the questions were asked after showing each message. The discussions were audio-recorded alongside note-taking by an experienced note-taker. Other team members observed the discussions remotely through Webex. Each focus group lasted approximately 2 hours. After each focus group, the research team met and discussed what issues needed to be probed further and which types of participants to recruit for the next discussion to ensure that we captured information that is reflective of cigarette smokers’ perspectives. Based on these discussions, the moderator guide was continually modified.

    Additional probes related to emerging themes in the participants’ interpretations of specific messages were recorded in the moderator and note-taker’s notes. These included probes to investigate the underlying attitudes and interpretations behind recurring perceptions that participants mentioned regarding the colours used in the images, the types of electronic and regular cigarettes in those messages and the age, gender and emotional state of people in the images and how these influenced their perceptions of the messages. The moderator only used those probes when participants referred to one of these aspects of the message.

    Data analysis

    The qualitative data were analysed inductively in NVivo V.11.0 using thematic analysis approach.25 All research team members read meaningful chunks26 of the data and met regularly to discuss emerging themes. The research team met to discuss the codes and develop an initial codebook for coding the transcripts. Transcripts from two focus groups were double-coded independently by researchers KH and BB, who then reviewed their coding for discrepancies. Consensus on definitions of codes or coding was reached through discussions among the two. More challenging discrepancies were resolved through consultation with the research team. Once a master codebook (online supplement C) had been developed, a single coder (KH) completed the coding of the rest of the transcripts. After coding all the transcripts, the research team conducted in-depth readings of the coded transcripts and wrote memos that discussed the themes. The lead author then read all the memos and corresponding transcripts and synthesised the results.

    Results

    Participants were 69% male; 74% African-American, 17% white and 10% other race; 58% had some college education and 30% had bachelor’s degree or higher; and 7%, 67% and 26% were aged 18–24, 25–44, 45+ years, respectively (table 1).

    View this table:
    Table 1

    Demographic characteristics of study participants

    Overall, messages comparing risks of e-cigarettes and combusted cigarettes generated animated discussions among participants, with the central themes of uncertainty about health effects of e-cigarettes and resultant scepticism about some of the message claims which some participants used as arguments to rationalise continued smoking. Yet participants appreciated messages that offered them options and made recommendations for message improvement, particularly including a credible source and facts and statistics.

    Uncertainty about health effects and chemical content of e-cigarettes

    The lack of definitive information about health harms and benefits of e-cigarettes and their chemical content in our messages and in the overall informational environment around e-cigarettes made participants concerned about e-cigarette use. Particularly, the uncertainty around e-cigarettes’ health harms was contrasted with the known harms of combusted cigarettes. Some participants felt that unknown risks of e-cigarettes were worse than the known risks of cigarettes. For instance, one person said: “Potential harms for regular cigarettes are strong and detrimental, but at least they are known. Since e-cigarettes are unknown then it opens to door to more potential harms” (male, 18–24).

    Whenever specific chemicals in e-cigarettes were mentioned, such as nicotine or formaldehyde, participants viewed e-cigarettes as very harmful and had difficulty reconciling this belief with the claim that e-cigarettes are less harmful than smoking. One participant said: “It doesn’t help that e-cigarettes contain addiction causing nicotine and harmful chemicals like formaldehyde. So they still contain this stuff, but are less harmful than regular cigarettes? I think this would make them more or less the same” (male, 18–24).

    Overt expressions of uncertainty presented in the messages (eg, ‘there is a lot we don’t know about e-cigarettes’) increased credibility of messages for some participants. However, many saw the uncertainty surrounding the health effects of e-cigarettes as incompatible with claims of lower risk, “Because you don’t know, there’s nothing, there’s no proof out there saying it’s less harmful than regular cigarettes” (male, 45–64). The lack of definitive answers was viewed as evidence of harm and alarmed some participants, because “the unknown can be so much [more] dangerous” (female, 25–44).

    Scepticism at the lack of facts and numbers

    Participants repeatedly asked for more facts in terms of numbers to back the claim that e-cigarettes are less harmful than cigarettes. Participants wanted to see why e-cigarettes are less harmful than cigarettes, by how much, and the empirical evidence and the source behind that information. The lack of this information suggested that the health effects of e-cigarettes were unknown, and the message developers were just interested in promoting e-cigarettes. The lack of quantified risk reduction associated with switching to e-cigarettes was viewed as deliberate concealment: “It makes me feel like you’re concealing stuff. Like, how much am I reducing, how much is this e-cigarette really helping me right now?” (male, 25–44).

    The lack of information regarding the source of the messages suggested to participants that the health effects of e-cigarettes were unknown and that the messages were from tobacco or e-cigarette companies. Participants concluded that messages could not be completely factual due to the assumed source and the baggage of negative perceptions of the tobacco industry. One participant explained, “these companies are not stupid. They are not going to go anywhere. They are going to switch you to something and convince you that it is better because they still want your money. E-cigarettes will have nicotine and some harmful chemicals, but they are less harmful. So the technology may help decrease your chances of getting cancer, but it is still going to bleed you in terms of money and your health” (male, 25–44).

    Scepticism at the combination of known and unknown information

    Participants had difficulty reconciling the acknowledgement of uncertainty (‘a lot we don’t know about e-cigarettes’) with assurance that e-cigarettes are less harmful based on what we know. Smokers felt this type of messaging was premature: “They haven’t done their homework because there is a lot that they don’t know” (female, 25–44). Furthermore, expression of ‘don’t know’ was seen as a means of avoiding liability for any future harms of e-cigarettes: “If someone shows up with a disease that only an e-cigarette can cause, they can turn around and say we told you that we didn’t know this entire time” (female, 45–64). Drawing on experiences with cigarettes also fuelled scepticism about the truthfulness of the message. One participant mentioned: “When regular cigarettes first came out, I’m sure they didn’t know it was causing all of this stuff. I think e-cigarettes are in the beginning stage right now” (female, 45–64).

    Scepticism based on the style and content of the text

    Participants were suspicious of words that connote uncertainties (eg, ‘can’). It was perceived that words such as ‘can’ and ‘may’ were disclaimers to avoid liability for negative health effects from e-cigarette use. Participants asserted that if e-cigarettes are less harmful than cigarettes, ‘will reduce your risk’ would be used instead of ‘can reduce’. Additionally, some factual information in ‘fine print’ appeared as an attempt to hide the truth and promote e-cigarettes at the expense of quitting, a healthier option. As one participant stated, “I like the fact that they put the healthiest option is to quit smoking because that’s a fact, but the way they made it I feel like it’s fine print, like they don’t really want you to read that stuff” (male, 25–44).

    Scepticism resulting from participants’ misconceptions and misunderstanding of the messages

    In some instances, scepticism of the messages stemmed from participants’ own misconceptions. Some participants believed that nicotine is the primary harmful chemical in cigarettes. Therefore, they did not expect e-cigarettes to contain nicotine. Thus, some participants did not understand why e-cigarettes are less harmful than cigarettes if they contain nicotine or if they are addictive. “He said that it has nicotine and I thought it didn’t which is why people were trying to use them to stop smoking regular cigarettes. Nicotine is supposed to cause cancer” (female, 45–64).

    Some participants misunderstood the messages or elements in the messages. A common source of misunderstanding was the language around complete switching to e-cigarettes. For example, participants frequently misinterpreted the message ‘When you switch to using e-cigarettes 100% of the time instead of traditional cigarettes, you can reduce your risk.’ Some participants interpreted the ‘100% of the time’ as vaping 24 hours a day, as indicated by the statement, “… 100% of the time is telling me, oh, you’re going to get addicted because you’re going to have to keep smoking” (male, 25–44). Some participants also interpreted ‘switching 100% of the time’ to mean that e-cigarettes are less harmful 100% of the time: “Doing it with an e-cigarette it just goes away, so 100% of the time it’s less harmful” (male, 25–44). Others thought ‘switching completely’ is more achievable than switching ‘100% of the time’ because ‘100% of the time’ was viewed as burdensome. As one participant explained, “Completely is easier to accept. 100% seems like a bigger task” (male, 25–44), indicating that switching ‘completely’ might not mean abandoning smoking altogether, ‘100% of the time’.

    Some participants seemed to intuitively interpret the phrase ‘less harmful’ as having no harm or toxic chemicals at all. Consequently, messages that mentioned some of the toxic chemicals in e-cigarettes confounded the participants, as one of them questioned: “They contain formaldehyde but are less harmful?” (male, 25–44).

    Using uncertainty and scepticism around e-cigarettes to rationalise continued smoking

    Participants used uncertainty and doubts around the health effects of e-cigarettes and the comparative risks between e-cigarettes and combusted cigarettes as arguments for continued smoking. In essence, ‘less harmful’ was viewed as ‘still harmful’ and provided no reason to switch. Some participants viewed smoking cigarettes that have known health effects ‘in moderation’ as a better alternative than vaping e-cigarettes that have unknown health risks: “Non-smokers have been going on for years and years trying to get people to stop smoking… A cigarette is not the best thing for you, but it is not poison. If you smoke one cigarette, you won’t be dead like arsenic or cyanide. There are so many unknowns” (male, 45–64). Some participants thought that any reduction in harm associated with e-cigarettes could be eroded by excessive vaping: “I don’t buy it. A lot of people will pull more smoke out of the vape pen than they would using regular cigarette. Also, if there is a flavor that you like, you are going to be pulling more often than you would on a regular cigarette. So, it may seem healthier because you are smoking less, but the dosages that you are pulling are higher with the vape pen than the regular cigarettes. It’s almost misleading” (male, 25–44). Additionally, some participants did not see the benefits in switching given the uncertainties: “I would keep smoking cigarettes. What is the point?” (female, 45–64).

    Recommendations for improvement

    While focus group participants responded to many questions with suggestions for improvements without being prompted, two questions were specifically asked regarding changes they would recommend to the messages. One asked about what could be done to improve the way a given message communicated comparative risk of cigarettes and e-cigarettes, and the other asked them to recommend changes that specifically encouraged complete switching to e-cigarettes (online Supplement B). To make comparative risk messages more believable, understandable and informative, participants recommended attributing messages to a credible source and using more facts and statistics. Messages from e-cigarettes/tobacco companies were perceived as having low credibility, for example, “When I see the message I think that there is a company marketing e-cigarettes and trying to bid out regular cigarettes. The e-cigarettes and regular cigarettes are comparable” (female, 25–44); “Like I said earlier, these companies are not stupid. They are not going to go anywhere. They are going to switch you to something and convince you that it is better because they still want your money” (male, 25–44). In contrast, the FDA, Centers for Disease Control and Prevention, Health Department, non-profit organisations (such as American Cancer Society) and academic institutions were considered credible sources.

    There was a consistent call for more facts to assist in informed decision-making. Participants equated facts with statistics and appreciated the use of numbers when comparing the toxic chemicals in cigarettes and e-cigarettes. Participants generally concluded that simply “saying that it is less harmful than cigarettes isn’t a fact” (male, 25–44). They wanted to know the quantified harm reduction from switching to e-cigarettes: “How much are you reducing by? Is it only 1%? If that is the case then I’m going to continue smoking my cigarette” (female, 25–44). Another participant suggested to “At least put it’s at least 50% less harmful. Put that 50% in there and it probably would have sold it” (female, 25–44). Besides numbers, participants described an emotional portrayal of harmful consequences of smoking as ‘hard facts’. These ‘hard facts’ were seen as truthful and made them consider either switching to e-cigarettes or quitting smoking completely.

    For some people, simply showing numbers made the message ‘stand out’, for example, “69 toxins and cancer-causing ingredients. That stands out to me” (male, 25–44). The statistics in the messages were offered as something ‘new’ in the messages that changed participants’ opinions about the relative harms of the two products, making them “think that cigarettes are worse” (male, 25–44). Participants also suggested that the risk comparison should include other tobacco products, such as cigarillos. “I would show e-cigarettes as compared to everything else that you could smoke if they’re less harmful than the other things” (male, 25–44).

    Finally, many participants appreciated the messages offering them ‘options’, such as the language: ‘The healthiest option is to quit for good, but if you are not ready, switch to e-cigarettes.’ They felt like it was “something a friend would tell you” (male, 45–64). As one participant put it, “I really like the phrase, “We know you are not ready to quit.” You’re right, I’m not. I’m always going to want to smoke. I’ll give switching a shot because they were nice about it” (male, 25–44).

    Discussion

    Communicating about the risk of e-cigarettes compared with cigarettes can help with informed decision-making by cigarette smokers. However, how to communicate about comparative risks remains a question. Our study qualitatively evaluated comparative risk messages among adult current smokers, which provided in-depth information about their reactions to different aspects of comparative risk messages.

    Participants interpreted uncertainty about health effects of e-cigarettes as an indicator of significant unknown risks. Some participants perceived unknown risks as more dangerous than the known risk of cigarettes, such as cancer, heart disease and death. This is consistent with research indicating that uncertainty disclosure may increase perceived risk.27 28 This perception made participants more sceptical about the benefits of switching to e-cigarettes, and some participants used the uncertainty to rationalise their decision to continue smoking. This finding suggests that comparative risk messages that aim at convincing smokers who are unwilling to quit using nicotine to switch to e-cigarettes may fail if they communicate uncertainty about e-cigarettes. Therefore, such messages should focus more on what is known rather than the unknown.

    Any mention of known chemicals in e-cigarettes (such as nicotine or formaldehyde) evoked negative reactions from participants who found it hard to believe that a product containing any amount of nicotine or formaldehyde could be ‘less dangerous’. The style of the messages can also generate scepticism and suspicion. Participants used the choice of words and formatting of the text to assess trustworthiness of the messages and the intent of the message developers. Messages in which known facts appeared to be in ‘fine print’ were viewed as an attempt to hide the truth and promote e-cigarettes. This made participants question the source of the messages, and some assumed that they were ads from e-cigarette/tobacco companies. Participants demonstrated distrust for tobacco companies and organisations with commercial interests in tobacco products due to their knowledge of tobacco industry deception. Therefore, to decrease scepticism about the messages, the messages should mention a trusted source, such as the FDA.29 30

    Presenting numerical information about reduction in risks resulting from an intervention is a prevalent approach in health risk communication and has been found to be understood better and trusted more than simple qualitative description of risk reduction.31 32 Consistently, participants wanted the messages to quantify the benefits or state how much risk from combusted tobacco would be reduced by switching completely to e-cigarettes. Currently, there is no consensus on how much less harmful e-cigarettes are relative to cigarettes, but the existing literature on the relative toxic chemicals in e-cigarettes may provide an avenue for communicating reduction in exposure. Indeed, participants liked messages communicating that cigarette smoke contained nine times more toxic ingredients than e-cigarettes. They also called for more side-by-side comparisons of chemical contents of both products.

    More studies are needed to understand how to develop effective numerical messages about the comparative risk of different tobacco products. One important direction would be to explore whether and how adding graphs can influence the effectiveness of text-based numerical comparative risk messages.31 Our study also suggested another strategy to improve comparative risk messages is to emphasise the risk of combusted cigarettes. Some participants were motivated to either switch or quit smoking due to the emphasis some of the messages placed on the more severe harms from smoking and others used the emphasis to judge the truthfulness of the message because these were known facts, hence, the messages themselves were presenting facts. This suggests that comparative risk messages may be effective if they mention the severe harms of combusted cigarettes.

    Limitations of the study include predominantly African-American participants, which could make the results reflective of one cultural view. This study also included only adult smokers with a few young adults (18–24 years). Future studies should assess how youth and young adult smokers, non-smokers and former smokers interpret comparative risk messages. Lastly, like all focus group discussions, we cannot rule out the influence of the group dynamics on the results. Despite these limitations, our findings have implications for the MRTP applications and communicating about e-cigarettes.

    Implications

    As of March 2019, the FDA is considering several MRTP applications for heated and smokeless tobacco products.14–16 In all cases, tobacco companies are asking permission to market these tobacco products with claims of reduced risk, such as ‘Switching completely to this product from cigarettes reduces risk of lung cancer.’16 Current evidence indicates that MRTPs will reduce harm only if smokers who are not willing to quit would switch to them completely.33 34 However, to date, there have been no conclusive studies showing that the public correctly understands what ‘switching completely’ means. Philip Morris International, in the MRTP application to the FDA for IQOS products27 used the term ‘switching completely’ but failed to demonstrate that the study participants understood what it means.35 In our study, some participants misinterpreted ‘switching 100% of the time’ as meaning ‘vaping non-stop throughout the day’. Though the term ‘completely switching’ was understood better, some participants viewed ‘completely switching’ as easier to achieve than switching ‘100% of the time’ which might indicate that at least some smokers view ‘switching completely’ as potentially compatible with dual use. Evidence regarding how e-cigarettes are used in the real world does not demonstrate that ‘switching completely’ has been the most common outcome but that dual and poly use are the most common form of use. For example, among US adults who use electronic cigarettes, 75%–82% use e-cigarettes in combination with at least one other form of combustible tobacco, and only 20% of e-cigarette users are recent quitters of combustible cigarettes.36 37 Given this fact, further research is needed on how to communicate to smokers the need to switch completely in comparative risk messages that would avoid misconceptions that might lead to dual use among smokers.

    Additionally, some participants interpreted ‘less harmful’ as ‘not harmful’. This misunderstanding may also result from the modified risk claims proposed by the tobacco companies27–29 and the FDA needs to carefully review the evidence tobacco companies are providing regarding how the public interpret reduced risk claims.

    The results of this qualitative study also have implications for comparative risk message development. First, a mixture of large and small fonts might lead consumers to infer that information presented in larger fonts is more important than information in fine print. Also, when the objective of comparative risk message is to help consumers to switch to e-cigarettes, messages that communicate what is known rather than unknown about e-cigarettes may be effective. Additionally, comparative risk messages may more likely be trusted if showing sources of the messages as entities without commercial interest in tobacco products. Therefore, these issues—consistent font, emphasising knowns over uncertainties, emphasising risks of smoking and providing the source—should be explored and tested further in the development of comparative risk messages.

    Conclusion

    Comparative risk messages from e-cigarette/tobacco companies may evoke scepticism about e-cigarettes. The scepticism may lead to continued cigarette smoking among smokers who are not ready to quit smoking. On the other hand, the use of trusted sources,29 30 38–40 statistical facts and emphasis on the known health harms of cigarettes in comparative risk messages were more compelling.

    What this paper adds

    • Research is needed to understand how to communicate about the comparative risk of electronic and combusted cigarettes. Qualitative studies provide important in-depth understanding of the issue, but these studies are scant.

    • This study qualitatively evaluated understanding and reactions to 12 comparative risk messages among adult current smokers.

    • Some participants misinterpreted what ‘switching completely’ or ‘switching 100% of the time’ meant.

    • Comparative risk messages from entities with a commercial interest in e-cigarettes/tobacco may lead to scepticism about e-cigarettes and harden smoking behaviour among smokers who are unwilling to quit. However, comparative risk messages from public health sources that emphasise what is known about e-cigarettes, the harm of smoking and the option of switching if one is not ready to quit may be more compelling in communicating about e-cigarettes to smokers.

    References

    1. ↵
      2. Alzahrani T ,
      3. Pena I ,
      4. Temesgen N , et al
      . Association between electronic cigarette use and myocardial infarction. Am J Prev Med 2018;55:455–61.doi:10.1016/j.amepre.2018.05.004
      OpenUrl
    2. ↵
      2. Behar RZ ,
      3. Luo W ,
      4. Lin SC , et al
      . Distribution, quantification and toxicity of cinnamaldehyde in electronic cigarette refill fluids and aerosols. Tob Control 2016;25(Suppl 2):ii94–102.doi:10.1136/tobaccocontrol-2016-053224
      OpenUrlAbstract/FREE Full Text
    3. ↵
      2. Carnevale R ,
      3. Sciarretta S ,
      4. Violi F , et al
      . Acute impact of tobacco vs electronic cigarette smoking on oxidative stress and vascular function. Chest 2016;150:606–12.doi:10.1016/j.chest.2016.04.012
      OpenUrlCrossRefPubMed
    4. ↵
      1. National Academies of Sciences, Engineering, and Medicine
      . Public health consequences of e-cigarettes. Washington, DC: The National Academies Press, 2018.
    5. ↵
      2. Behar RZ ,
      3. Wang Y ,
      4. Talbot P
      . Comparing the cytotoxicity of electronic cigarette fluids, aerosols and solvents. Tob Control 2018;27:325–33.doi:10.1136/tobaccocontrol-2016-053472
      OpenUrlAbstract/FREE Full Text
    6. ↵
      2. Goniewicz ML ,
      3. Knysak J ,
      4. Gawron M , et al
      . Levels of selected carcinogens and toxicants in vapour from electronic cigarettes. Tob Control 2014;23:133–9.doi:10.1136/tobaccocontrol-2012-050859
      OpenUrlAbstract/FREE Full Text
    7. ↵
      2. Abrams DB ,
      3. Glasser AM ,
      4. Pearson JL , et al
      . Harm minimization and tobacco control: Reframing societal views of nicotine use to rapidly save lives. Annu Rev Public Health 2018;39:193–213.doi:10.1146/annurev-publhealth-040617-013849
      OpenUrl
    8. ↵
      2. McNeil A ,
      3. Brose LS ,
      4. Calder R , et al
      . E-cigarettes: an evidence update. A report commissioned by Public Health England [Internet]. Public Health England, 2016. Available: http://tobacco.cleartheair.org.hk/wp-content/uploads/2015/08/PHE-e-cig-review-summary-Aug-2015.pdf
    9. ↵
      2. McNeill A ,
      3. Munafò MR
      . Reducing harm from tobacco use. J Psychopharmacol 2013;27:13–18.doi:10.1177/0269881112458731
      OpenUrlCrossRefPubMedWeb of Science
    10. ↵
      2. Coleman B ,
      3. Rostron B ,
      4. Johnson SE , et al
      . Transitions in electronic cigarette use among adults in the population assessment of tobacco and Health (path) study, waves 1 and 2 (2013–2015). Tob Control 2018.doi:10.1136/tobaccocontrol-2017-054174
    11. ↵
      2. Grana RA ,
      3. Ling PM ,
      4. Benowitz N , et al
      . Electronic cigarettes. Circulation 2014;129:e490–2.doi:10.1161/CIRCULATIONAHA.114.008545
      OpenUrlFREE Full Text
    12. ↵
      1. US Food and Drug Administration
      . Deeming tobacco products to be subject to the Federal Food, Drug, and Cosmetic Act, as amended by the Family Smoking Prevention and Tobacco Control Act; restrictions on the sale and distribution of tobacco products and required warning statements for tobacco products, 2016. Available: https://www.federalregister.gov/documents/2016/05/10/2016-10685/deeming-tobacco-products-to-be-subject-to-the-federal-food-drug-and-cosmetic-act-as-amended-by-the
    13. ↵
      1. U.S. Food and Drug Administration
      . Guidance for the industry: modified risk tobacco product applications. Available: https://www.fda.gov/downloads/TobaccoProducts/GuidanceComplianceRegulatoryInformation/UCM297751.pdf
    14. ↵
      1. U.S. Food and Drug Administration
      . Philip Morris products S.A. Modified risk tobacco product (MRTP) applications, 2017. Available: https://www.fda.gov/tobaccoproducts/labeling/marketingandadvertising/ucm546281.htm
    15. ↵
      1. U.S. Food and Drug Administration
      . R.J. Reynolds tobacco company modified risk tobacco product (MRTP) applications, 2017. Available: https://www.fda.gov/TobaccoProducts/Labeling/MarketingandAdvertising/ucm564399.htm
    16. ↵
      1. U.S. Food and Drug Administration
      . U.S. Smokeless Tobacco Company modified risk tobacco product (MRTP) application, 2018. Available: https://www.fda.gov/TobaccoProducts/Labeling/MarketingandAdvertising/ucm619683.htm
    17. ↵
      2. Banerjee SC ,
      3. Greene K ,
      4. Li Y , et al
      . The effect of comparatively-framed versus similarity-framed e-cigarette and snus print ads on young adults' AD and product perceptions. Tob Regul Sci 2016;2:214–29.doi:10.18001/TRS.2.3.2
      OpenUrl
    18. ↵
      2. Barnes AJ ,
      3. Bono RS ,
      4. Lester RC , et al
      . Effect of flavors and modified risk messages on e-cigarette abuse liability. Tob Regul Sci 2017;3:374–87.doi:10.18001/TRS.3.4.1
      OpenUrl
    19. ↵
      2. Berry C ,
      3. Burton S ,
      4. Howlett E
      . The impact of e-cigarette addiction warnings and health-related claims on consumers’ risk beliefs and use intentions. Journal of Public Policy & Marketing 2017;36:54–69.doi:10.1509/jppm.15.024
      OpenUrl
    20. ↵
      2. Jo CL ,
      3. Golden SD ,
      4. Noar SM , et al
      . Effects of e-cigarette advertising messages and cues on cessation outcomes. Tob Regul Sci 2018;4:562–72.doi:10.18001/TRS.4.1.3
      OpenUrl
    21. ↵
      2. Pepper JK ,
      3. Byron MJ ,
      4. Ribisl KM , et al
      . How hearing about harmful chemicals affects smokers' interest in dual use of cigarettes and e-cigarettes. Prev Med 2017;96:144–8.doi:10.1016/j.ypmed.2016.12.025
      OpenUrl
    22. ↵
      2. Pepper JK ,
      3. Emery SL ,
      4. Ribisl KM , et al
      . Effects of advertisements on smokers' interest in trying e-cigarettes: the roles of product comparison and visual cues. Tob Control 2014;23 Suppl 3(suppl 3):iii31–6.doi:10.1136/tobaccocontrol-2014-051718
      OpenUrl
    23. ↵
      2. Wackowski OA ,
      3. O'Connor RJ ,
      4. Strasser AA , et al
      . Smokers' and e-cigarette users' perceptions of modified risk warnings for e-cigarettes. Prev Med Rep 2016;4:309–12.doi:10.1016/j.pmedr.2016.07.005
      OpenUrl
    24. ↵
      2. Yang B ,
      3. Owusu D ,
      4. Popova L
      . Testing messages about comparative risk of electronic cigarettes and combusted cigarettes. Tob Control 2018. doi:doi:10.1136/tobaccocontrol-2018-054404.
    25. ↵
      2. Braun V ,
      3. Clarke V
      . Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101.doi:10.1191/1478088706qp063oa
      OpenUrlCrossRef
    26. ↵
      2. Ashcroft K ,
      3. Barrow F ,
      4. Lee R , et al
      . Mindfulness groups for early psychosis: a qualitative study. Psychol Psychother Theory Res Pract 2012;85:327–34.doi:10.1111/j.2044-8341.2011.02031.x
      OpenUrl
    27. ↵
      2. Johnson BB ,
      3. Slovic P
      . Presenting uncertainty in health risk assessment: initial studies of its effects on risk perception and trust. Risk Anal 1995;15:485–94.doi:10.1111/j.1539-6924.1995.tb00341.x
      OpenUrlCrossRefPubMedWeb of Science
    28. ↵
      2. Johnson BB ,
      3. Slovic P
      . Lay views on uncertainty in environmental health risk assessment. J Risk Res 1998;1:261–79.doi:10.1080/136698798377042
      OpenUrlCrossRef
    29. ↵
      2. Weaver SR ,
      3. Jazwa A ,
      4. Popova L , et al
      . Worldviews and trust of sources for health information on electronic nicotine delivery systems: effects on risk perceptions and use. SSM Popul Health 2017;3:787–94.doi:10.1016/j.ssmph.2017.09.003
      OpenUrl
    30. ↵
      2. Owusu D ,
      3. Weaver SR ,
      4. Yang B , et al
      . Trends in trust in the sources of health information on e-cigarettes among US adults, 2015-2017. Am J Public Health 2018:e1–3.doi:10.2105/AJPH.2018.304754
    31. ↵
      1. U.S. Food and Drug Administration
      . Communicating risks and benefits: An evidence-based user’s guide 2011.
    32. ↵
      2. Lipkus IM
      . Numeric, verbal, and visual formats of conveying health risks: suggested best practices and future recommendations. Med Decis Making 2007;27:696–713.doi:10.1177/0272989X07307271
      OpenUrlCrossRefPubMedWeb of Science
    33. ↵
      2. Goniewicz ML ,
      3. Gawron M ,
      4. Smith DM , et al
      . Exposure to nicotine and selected toxicants in cigarette smokers who switched to electronic cigarettes: a longitudinal within-subjects observational study. Nicotine Tob Res 2017;19:160–7.doi:10.1093/ntr/ntw160
      OpenUrlCrossRefPubMed
    34. ↵
      2. Kalkhoran S ,
      3. Glantz SA
      . Modeling the health effects of expanding e-cigarette sales in the United States and United Kingdom: a Monte Carlo analysis. JAMA Intern Med 2015;175:1671–80.doi:10.1001/jamainternmed.2015.4209
      OpenUrl
    35. ↵
      2. McKelvey K ,
      3. Popova L ,
      4. Kim M , et al
      . IQOS labelling will mislead consumers. Tob Control 2018;27(Suppl 1):s48–54.doi:10.1136/tobaccocontrol-2018-054333
      OpenUrlAbstract/FREE Full Text
    36. ↵
      2. Kasza KA ,
      3. Ambrose BK ,
      4. Conway KP , et al
      . Tobacco-Product use by adults and youths in the United States in 2013 and 2014. N Engl J Med 2017;376:342–53.doi:10.1056/NEJMsa1607538
      OpenUrlPubMed
    37. ↵
      2. Weaver SR ,
      3. Majeed BA ,
      4. Pechacek TF , et al
      . Use of electronic nicotine delivery systems and other tobacco products among USA adults, 2014: results from a national survey. Int J Public Health 2016;61:177–88.doi:10.1007/s00038-015-0761-0
      OpenUrlCrossRefPubMed
    38. ↵
      2. Blendon RJ ,
      3. Benson JM ,
      4. Hero JO
      . Public trust in physicians--U.S. medicine in international perspective. N Engl J Med 2014;371:1570–2.doi:10.1056/NEJMp1407373
      OpenUrlCrossRefPubMed
    39. ↵
      2. Case KR ,
      3. Lazard AJ ,
      4. Mackert MS , et al
      . Source credibility and e-cigarette attitudes: implications for tobacco communication. Health Commun 2018;33:1059–67.doi:10.1080/10410236.2017.1331190
      OpenUrl
    40. ↵
      2. Wackowski OA ,
      3. Delnevo CD
      . Smokers' attitudes and support for e-cigarette policies and regulation in the USA. Tob Control 2015;24:543–6.doi:10.1136/tobaccocontrol-2014-051953
      OpenUrlAbstract/FREE Full Text

    Footnotes

    • 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.