Article Text

Download PDFPDF
Older age is associated with greater misperception of the relative health risk of e-cigarettes and cigarettes among US adults who smoke
  1. Dana Rubenstein1,2,
  2. Rachel L Denlinger-Apte3,
  3. Jennifer Cornacchione Ross4,
  4. Dana Mowls Carroll5,
  5. F Joseph McClernon1,2
  1. 1Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
  2. 2Clinical and Translational Science Institute, Duke University School of Medicine, Durham, North Carolina, USA
  3. 3Social Sciences and Health Policy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
  4. 4Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
  5. 5Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
  1. Correspondence to Dana Rubenstein, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC 27705, USA; dana.rubenstein{at}


Introduction The prevalence of cigarette smoking among adults aged ≥55 has remained stagnant over the past decade. National data modelling suggests no reduction in cigarette smoking prevalence attributable to e-cigarette use in the USA among people aged ≥45. Misperceptions about the absolute risks (ie, cigarettes are not harmful) and relative risks (ie, e-cigarettes are more harmful than cigarettes) of tobacco products may contribute to sustained smoking prevalence and hesitancy to switch from cigarettes to e-cigarettes among older adults.

Methods Participants reported cigarette use (n=8072) at Wave 5 (2018–2019) of the Population Assessment of Tobacco and Health Study. Weighted multivariable logistic regressions included six age categories (independent variable) and cigarette and e-cigarette risk perceptions (outcomes). Additional models assessed the associations between dichotomous age (≥55 vs 18–54), risk perceptions and an interaction term (independent variables) with past 12-month quit attempts and past-month e-cigarette use (outcomes).

Results Adults aged ≥65 were less likely than adults aged 18–24 to rate cigarettes as very/extremely harmful (p<0.05). Odds of rating e-cigarettes as more harmful than cigarettes among adults aged 55–64 and ≥65 were 1.71 (p<0.001) and 1.43 (p=0.024) greater than for adults aged 18–24. This misperception was negatively associated with past-month e-cigarette use and was stronger among adults aged ≥55 (p<0.001) than adults aged <55 (p<0.001).

Discussion Adults aged ≥55 are more likely to have misperceptions about the absolute and relative risks of tobacco products, which may contribute to continued smoking. Health communications targeting this age group could modify beliefs about the perceived harms of tobacco products.

  • Electronic nicotine delivery devices
  • Priority/special populations
  • Harm Reduction

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Twitter @RubensteinDana, @dmowls

  • Contributors DR, RLD-A, JCR and FJM conceptualised the manuscript. DR analysed the data and wrote the first draft. DR, RLD-A, JCR, DMC and FJM interpreted the data and contributed to subsequent drafts. All authors critically revised the manuscript and contributed intellectual content. FJM is the guarantor and accepts full responsibility for the finished article.

  • Funding Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (award number TL1 TR002555). This work was also funded by the National Institute on Minority Health and Health Disparities (K01MD014795; DMC).

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

  • 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.