Article Text
PDF
Abstract
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
Statistics from Altmetric.com
Introduction
In the USA, an outbreak of serious vaping-related lung injuries (dubbed ‘EVALI’, which stands for “e-cigarette or vaping product use-associated lung injury”) emerged in June 2019, peaked in September 2019, and led to over 2800 hospitalised cases by February 2020.1 Although emerging cases suggested an important link with vaping tetrahydrocannabinol (THC), the main psychoactive ingredient of cannabis, communications from the Centres for Disease Control and Prevention (CDC) through October 2019 urged concerned individuals to consider refraining from using all e-cigarette and vaping products during its investigation, in addition to warning about THC vaping products, particularly those from informal sources.2 The CDC subsequently identified vitamin E acetate, an additive in some THC vaping products, as a ‘chemical of concern’3 and by January 2020 had confirmed that most patients with EVALI had used THC-containing vaping devices, rather than nicotine-based e-cigarettes/vapes.4
The extent to which the public followed and understood the EVALI investigation is unclear. Although the EVALI outbreak received substantial news coverage during its peak,5 6 coverage declined with the subsequent fall in cases and the onset of COVID-19. The CDC posted its last EVALI web page update on 25 February 2020,1 shortly before COVID-related shutdowns across the USA in March 2020. Furthermore, early news discussion of EVALI often simultaneously discussed the high prevalence of youth vaping and JUUL popularity, potentially conflating these issues and products.6 7 A US poll assessing EVALI awareness in January 2020, 4 months after its peak, found more respondents linked EVALI with using e-cigarettes like JUUL (66%) than with vaping THC (28%).8
Studies in the USA and elsewhere have documented increases in e-cigarette harm perceptions after the EVALI outbreak.9–14 However, limited research has focused on knowledge of EVALI itself or EVALI’s impact on smokers’ e-cigarette perceptions and intentions. This is important given e-cigarettes’ potential to reduce adverse health effects in smokers who switch to them.15 We aimed to explore US smokers’ recall and knowledge of EVALI over a year after the outbreak, and to assess any lasting effects on perceptions of and interest in using e-cigarettes.
Methods
Participants and procedures
Data came from a broader online survey about modified risk products and messages (conducted January–February 2021) with 1018 adult current smokers (aged 18+ years, smoked at least 100 lifetime cigarettes and now smoke every day or some days). Participants were recruited by Ipsos from their KnowledgePanel, a commercial web panel designed to be representative of the US population, using probability-based panel recruitment (address sampling via the US Postal Service’s Delivery Sequence File) and survey weighting procedures.16 To recruit 1000 smokers, Ipsos invited a sample of 1852 panel participants believed to be smokers; 1171 (63%) completed eligibility questions and 1018 confirmed smokers completed the survey.
Measures
As part of the broader study, four EVALI-related measures were developed and refined through cognitive interviews with 15 smokers and young adult non-smokers.17 To assess EVALI awareness/recall, participants were asked, ‘Before COVID-19, did you hear about people getting very sick or dying from an outbreak of serious lung illnesses caused by vaping?’ (yes, no, not sure). Those answering yes were asked three follow-up questions. The first asked, ‘To the best of your knowledge, which type of product was the MAIN cause of these vaping-related illnesses and deaths?‘ Response options were: (1) E-cigarettes used to vape nicotine, like JUUL; (2) Vaping products used for vaping marijuana or THC; (3) Both were responsible; (4) I don’t know. The second asked, ‘Have you heard of vitamin E acetate as being associated with this outbreak of vaping lung illnesses?’ (yes, no, not sure). The third follow-up question asked, ‘What effect, if any, has this outbreak of vaping-related lung illnesses had on your interest in using e-cigarettes/vaping products in the future?’ Response options were: (1) Because of these vaping illnesses, I am less interested in using e-cigarettes in the future; (2) Because of these vaping illnesses, I am more interested in using e-cigarettes in the future; (3) The vaping lung illness outbreak has had no effect on my interest in using e-cigarettes in the future. The survey also asked about ever and past 30-day use of e-cigarettes/vaping products, and perceived harm of e-cigarettes/vaping products relative to cigarette smoking (less harmful, about the same, more harmful, don’t know).
Analyses
We provided weighted prevalence estimates (with 95% CIs) of responses about EVALI awareness, knowledge and impact on e-cigarette interest. χ2 tests examined associations between EVALI awareness and (1) Participant demographics, (2) E-cigarette risk perceptions (significance levels at 0.05). Among those aware of EVALI, χ2 tests also examined associations between e-cigarette use (never, former and past 30-day use) and (1) EVALI knowledge and (2) EVALI-related e-cigarette use interest.
Results
Most participants smoked daily (79.1%), 55.7% had tried an e-cigarette/vape before and 11.3% had vaped in the past 30 days (see table 1 for additional demographics).
Sample characteristics and prevalence and correlates of smokers having heard of EVALI (n=1018)
EVALI awareness and knowledge
Approximately 54% of smokers had heard of EVALI (table 1). Awareness was significantly associated with e-cigarette use and was highest among former e-cigarette users (59.8%). Among those who had heard of EVALI, 37.3% believed that its main cause was e-cigarettes used to vape nicotine, like JUUL (table 2). Fewer (16.6%) indicated that products used for vaping marijuana/THC were the main cause. Perceived main cause of EVALI was significantly associated with e-cigarette use, with current users more frequently indicating vaping marijuana/THC as the main cause (47.8%, table 2). Among smokers aware of EVALI, 29.4% had heard of the association with vitamin E acetate (table 2). This awareness was more prevalent among those who had vaped in the past 30 days (67.4%).
EVALI knowledge and perceived impact on e-cigarette interest among smokers aware of EVALI (n=542), by e-cigarette use status
Having heard of EVALI was also associated with e-cigarette risk perceptions (p<0.0001). Most smokers thought e-cigarettes were about as harmful (40.0%) or more harmful than cigarettes (22.0%), and the perception that e-cigarettes are more harmful was more prevalent among those who were aware of EVALI (26.6%) vs not (16.8%) (see online supplemental table 1). Smokers who had heard of EVALI were also less likely to indicate uncertainty about the risks of e-cigarettes compared with cigarettes, relative to those not aware of EVALI (20.3% vs 31.4%).
Supplemental material
Perceived impact of EVALI on interest in using e-cigarettes
Among smokers who had heard of EVALI, 50.9% indicated that it made them less interested in using e-cigarettes in the future (table 2). E-cigarette use was significantly associated with perceived EVALI impact, with never (51.1%) and former e-cigarette users (53.9%) more likely to indicate reduced interest in e-cigarettes following the EVALI outbreak than those who used e-cigarettes currently (33.4%) (table 2). Further, what smokers believed to be the main cause of EVALI was also associated with perceived EVALI impact (p<0.0001). Those who thought e-cigarettes used to vape nicotine were the main cause of EVALI were more likely to indicate reduced interest in e-cigarettes following the EVALI outbreak (58.5%) compared with those who thought products for vaping THC were the main cause (34.9%) (see online supplemental table 2).
Supplemental material
Discussion
Approximately a year after the CDC’s last EVALI web page update and 16 months after the outbreak’s peak, about half of US smokers recalled hearing about EVALI prior to COVID-19. Considerable uncertainty and misperceptions remained, with about a third of smokers believing that e-cigarettes used to vape nicotine, like JUUL, were the main cause of EVALI, and a fifth indicating they did not know what the main cause was. A minority of participants correctly identified vaping marijuana/THC as the main cause. The common belief that nicotine-containing products were the main cause of EVALI (despite exclusive use of these products being self-reported by only 14% of cases4) implies a substantial misperception of the evidence.
These findings may have been shaped by early CDC/official communications that warned about use of any e-cigarette/vaping products, as well as public exposure to media coverage simultaneously discussing other e-cigarette issues—including growing e-cigarette use among youth, attributed to flavoured products and JUUL.6 7 9 Additionally, lawmakers passed numerous local and state bans on flavoured e-cigarettes in the wake of EVALI,18 likely reinforcing conflation of these issues for the public. It has also been argued that misperceptions may have been reinforced by the outbreak’s assigned name, EVALI, which begins with the term ‘e-cigarettes’ even though this term is not typically used by consumers who vape THC.19
Perceptions of EVALI may also relate to perceived issue relevance. Most smokers in this study did not currently use e-cigarettes, and EVALI knowledge was lower among these participants compared with those who also vaped. Dual processing communication theories suggest people process less personally relevant messages more ‘peripherally’, often making judgements using superficial heuristics,20 which, in the current case, may have included simultaneous headlines around EVALI and other e-cigarette issues (JUUL, e-cigarette bans).
Overall, these findings add to concerns that EVALI-related misperceptions may discourage tobacco smokers from switching to less harmful products,10 11 15 as about half the smokers in this study reported being less interested in future e-cigarette use because of EVALI. Findings may lend support to efforts to correct EVALI misperceptions, such as, for example, a recent letter from a large group of experts petitioning the CDC to rename EVALI (proposing ‘Adulterated THC Vaping Associated Lung Injury’), dropping e-cigarettes from the name19 (a proposal subsequently denied).21 More careful attention to terminology may help avoid similar misperceptions in the future. Furthermore, given that e-cigarette harm misperceptions had been increasing among US adults prior to EVALI,22 broader efforts around e-cigarettes may be needed (eg, more balanced news reporting, healthcare provider training, statements from officials/health organisations) if the potential risks and benefits of such products are to be clearly communicated to the public.15 Moving forward, similar efforts may be appropriate for other new nicotine products that may have harm-reduction potential (eg, tobacco-free nicotine pouches).
Limitations include use of cross-sectional data, a focus on US smokers (limiting generalisability), and a relatively small number of past 30-day e-cigarette users (resulting in some small cell sizes in e-cigarette use comparisons), among whom the behaviour of vaping THC was not specifically assessed. While the study included a question about EVALI’s impact on future e-cigarette interest, it did not assess how EVALI may have already impacted e-cigarette use (past behaviour). Also, the question asking about vitamin E acetate could have resulted in overestimates of its connection to EVALI by referring directly to it in the question stem, rather than including it in a list of items.
At our current moment where trust in scientific findings is vital but often called into question, it is important that the public receives accurate information about health issues like EVALI, as well as e-cigarettes/vaping products in general and other newer nicotine products. Appropriate responses among the public and action at the policy level depend on such informational accuracy and appropriate risk perceptions. Looking forward, public health experts may be able to promote better understanding of EVALI—and of other emergent issues in tobacco control—through collaborations with key public-facing actors including media and lawmakers.
What this paper adds
Limited research exists on the public’s knowledge surrounding the cause of the 2019 vaping-related lung illness outbreak (known as EVALI, which stands for “e-cigarette or vaping product use-associated lung injury”), and how this may have impacted e-cigarette perceptions and use.
This survey study of smokers in the USA finds that, about 16 months after EVALI’s peak, most smokers still did not know it was mainly caused by vaping marijuana.
This study also provides new data about the impact of EVALI on smokers’ interest in using e-cigarettes/vaping products.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the Rutgers Biomedical Health Sciences Institutional Review Board at Rutgers University (Pro2020002895). Participants gave informed consent to participate in the study before taking part.
Acknowledgments
The authors thank Nishi Gonsalves for her assistance with data analysis and preparation.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
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.