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Over 1 year later: smokers’ EVALI awareness, knowledge and perceived impact on e-cigarette interest
  1. Olivia A Wackowski1,2,
  2. Stefanie Kristen Gratale1,
  3. Michelle Jeong1,2,
  4. Cristine D Delnevo1,2,
  5. Michael B Steinberg1,3,
  6. Richard J O'Connor4
  1. 1 Center for Tobacco Studies, Rutgers University, New Brunswick, New Jersey, USA
  2. 2 Deptartment of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
  3. 3 Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
  4. 4 Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York, USA
  1. Correspondence to Dr Olivia A Wackowski, Center for Tobacco Studies, Rutgers University New Brunswick, New Brunswick, USA; wackowol{at}


Objectives The e-cigarette or vaping product use-associated lung injury (EVALI) outbreak caused serious lung injuries in over 2800 people in the USA in 2019. By February 2020, most cases were determined as linked with vaping tetrahydrocannabinol (THC), including black market products using vitamin E acetate. This study examined smokers’ EVALI awareness, knowledge and perceived impact on their e-cigarette interest approximately 16 months after its peak.

Design Between January and February 2021, we surveyed 1018 adult current smokers from a nationally representative US research panel. Participants were asked if they had heard about EVALI prior to COVID-19, knew its main cause, and if EVALI had impacted their interest in future e-cigarette use.

Results Approximately 54% of smokers had heard of EVALI. Among those who had heard of EVALI (n=542), 37.3% believed its main cause was e-cigarettes used to vape nicotine, like JUUL. Fewer (16.6%) thought the main cause was products for vaping marijuana/THC, and 20.2% did not know. About 29% had heard vitamin E acetate was associated with EVALI, and 50.9% indicated EVALI made them less interested in using e-cigarettes in the future. EVALI awareness was significantly associated with e-cigarette risk perceptions (ie, that e-cigarettes are as harmful as smoking).

Conclusions Despite the passage of time, considerable lack of knowledge and misperceptions about EVALI remain among those who smoke. Our findings suggest the need for continued efforts to promote better understanding of EVALI and appropriate behavioural and policy responses.

  • electronic nicotine delivery devices
  • public opinion
  • harm reduction

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  • Twitter @owackowski, @crisdelnevo

  • Contributors OAW designed the study, obtained study funding, and led data analysis and manuscript writing. SKG and MJ contributed to paper writing and editing. CDD, MBS and RJO provided critical feedback on manuscript drafts and contributed to manuscript editing.

  • Funding This work was supported by the National Cancer Institute (NCI) of the National Institutes of Health under Award Number R37CA222002. Contributions by MJ were supported by K01CA242591, and those by CD and MBS were supported in part by R01CA190444, also from the NCI. Contributions by SKG and CD were also supported by U54CA229973 from the NCI and the Food and Drug Administration. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding organisations.

  • Competing interests None declared.

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

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.