Smokers Awareness and Risk Perceptions of Filter Ventilation

Abstract

Objectives:

The addition of tiny rows of holes in the tipping paper (filter ventilation) of cigarettes allows air to mix with the smoke, which can change risk perceptions. In this study, we examine smokers’ knowledge and beliefs about filter ventilation.

Methods:

Web-based panel surveys conducted in 2016 and 2017 of current adult cigarette smokers (N = 2355) provided data on awareness and understanding of filter vents in their cigarettes, whether they believed blocking the holes would change the taste of their cigarettes, and their perceptions about their future risk of being diagnosed with lung cancer. The most commonly used cigarette brands reported by participants also were characterized on the presence and level of ventilation holes.

Results:

Approximately 40% of participants (mostly younger and male) reported awareness of the filter ventilation in their cigarettes. Only 30% of the participants were both aware of and understood the function of filter ventilation; they also were significantly more likely to worry about developing lung cancer.

Conclusion:

Although misleading descriptors associated with filter ventilation are prohibited, most smokers still smoked cigarettes with filter vents, and many are unaware and misunderstand the potential risks of filter ventilation.

Cigarette filter ventilation, the use of perforations in the tipping paper that wrap the cigarette filter, has been a key feature of cigarettes since the 1970s and is a feature on most cigarettes today. Currently, 99.7% of manufactured cigarettes sold in the United States (US) have a filter, and most of these have some degree of filter venting.^1,2 Filter ventilation increases air flow during puffing, dilutes the smoke with fresh air, and is used by the tobacco industry as a means of reducing smoking machine tar and nicotine yields, thereby changing consumer perceptions of harshness and risk.³ However, this ubiquity does not mean it is benign.⁴ As smokers use these ‘reduced yield’ cigarettes, they may compensate by changing their smoking behavior in ways that influence their exposure to nicotine and other smoke constituents.⁵ Filter ventilation may cause some smokers to smoke more cigarettes per day and/or change how they puff on cigarettes, including taking more frequent puffs per cigarette as well as puffing more intensely on the cigarettes they smoke because of a lower resistance to draw.⁶ Air dilution of the smoke due to filter ventilation also cools the smoke, thereby reducing the perceived harshness of smoke inhalation for some smokers. This reduced harshness of cigarette smoke may be interpreted by some smokers as meaning that the cigarettes pose lower health risks compared to other brands,⁷ which may, in turn, dissuade quitting.^8–10 Moreover, the degree of filter ventilation may be associated with the sensory properties of smoke.^11–15 However, it is now well established that smokers of so-called low tar and light cigarettes do not have reduced risk of disease.^8,16–21 There is also evidence that filter ventilation changes the process of combustion so as to impact smoke constituent yields, increasing mutagenicity and contributing to the increasing prevalence of adenocarcinoma of the lung in smokers.⁴ Other evidence suggests that filter ventilation contributes to cigarette abuse liability²² or dependence potential.

In 1996, Kozlowski et al²³ published the first study of filter ventilation awareness among US smokers. At that time, less than half of smokers reported having heard of filter vents; most were unaware of their purpose. Nearly a decade later, Cummings et al²⁴ showed that only 32% of Marlboro Lights smokers (the leading selling US brand of ventilated cigarette) correctly reported that the filters on their cigarettes were ventilated.

Much has changed in the tobacco marketplace over the last 10–15 years, including the US Federal Trade Commission’s 2008 decision to rescind the standard machine-produced measures of tobacco smoke constituents, citing them as misleading to consumers.²⁵ There also have been continuing declines in smoking prevalence²⁶ in the US, driven in part, by broad anti-smoking advertising campaigns such as Tips from Former Smokers,^27,28 Truth,^29,30 and The Real Cost,³¹ which have highlighted industry deception. The FDA now regulates tobacco products, including a 2010 ban on misleading descriptors (‘light’, ‘mild’, and ‘low), which are commonly associated with ventilation.³² Finally, the tobacco landscape has been transformed by the emergence of alternative nicotine delivery products such as e-cigarettes and other vaping devices. The current study examined awareness of filter ventilation among a sample of smokers recruited from Web-based panels in 2016–17. We also examined whether awareness of the presence or function of vents was associated with perceptions of risk and the sensory effects of smoking, because these are closely linked with ventilation. Finally, in a subset of participants from whom we obtained data on actual filter ventilation levels, we assessed the association between ventilation level and sensory and risk perceptions. We hypothesized that awareness should have increased given descriptor bans and attention brought to deception by industry, particularly around light cigarettes.

METHODS

Participants

Data for this study come from Web-based surveys administered in July-August 2016 and July-August 2017 to adult (18+) US respondents invited from GMI/Lightspeed (Global Market Insite (http://www.gmi-mr.com/global-panel/index.php) survey panels. Membership in their panels involves a double opt-in process (online registration form confirmed by email link). All participants were invited to respond to the survey via email and were deemed eligible if they were between the ages of 18 and 65 and provided consent. The overall intent of the surveys was to assess consumer perception and response around Modified Risk Tobacco Product (MRTP) messaging; we added questions to assess cigarette filter ventilation. Respondents were compensated 60 GMI “marketpoints” (20 marketpoints = 1 USD) for their time. For adults, smoking status was determined based on responses to the following questions: (1) “Have you ever smoked a cigarette, even a few puffs?” (2) “Have you smoked at least 100 cigarettes in your lifetime?” and (3) “Do you now smoke cigarettes?” We defined a current smoker as someone who reported smoking every day or some days and reported having smoked at least 100 cigarettes lifetime. The initial analytical sample was 2355 current cigarette smokers (1214 surveyed in 2016 and 1141 surveyed in 2017).

Measures

Questions on awareness and functions of ventilation were adapted from Kozlowski et al.²³ We asked: (1) Have you ever seen or have you ever heard that there are one or more rings of small holes around the filters of some cigarettes? (Aware – Y/N/Don’t know); and (2) Do you think that covering or blocking these filter holes would make a cigarette taste stronger, milder, or have no effect? (Understand – 7-point scale ranging from ‘A lot stronger’ to ‘No effect (4)’ to ‘A lot milder’, plus ‘Don’t know’). We coded those who responded < 4 as understanding the effects of ventilation. We asked all smokers whether their usual brand of cigarette was harsher/smoother and lighter/more intense compared to other cigarettes on the market. Participants who reported smoking a cigarette within the last 3 hours also completed a Cigarette Evaluation Scale (CES), a validated measure of sensory response to smoking.³³ We asked participants whether they had smoked a cigarette in the last hour, more than one but less than 3 hours, or ≥ 3 hours ago. Participants responding to the first 2 options received the CES questions. Preliminary analysis showed no statistically significant difference in responses between those who smoked in the last hour and those smoking up to 3 hours prior. Thus, we pooled the responses. We asked participants to rate how worried they were about lung cancer, rate their perceived risk of lung cancer relative to another smoker (much less - much more), as well as their perceived risks of 9 smoking-associated conditions (lung cancer, emphysema, mouth cancer, heart disease, bronchitis, stroke, tooth loss, abscesses, nicotine addiction) relative to a nonsmoker of their age (much less - much more). The latter scores were summed into an overall smoking health risk scale for analysis (Cronbach’s alpha = .95).

We assessed cigarette brand preference as a free response item, with participants asked to provide as much detail as possible to identify their specific sub-brand. We re-coded responses into categorical values to identify the most popular brands (eg, Marlboro, Newport), sub-brand (eg, Blue; Supreme; Special Blend), size (king, 100) and flavor (menthol, nonmenthol). If size and flavor were omitted, the default values were assumed to be king (86.1%) and nonmenthol (82.8%), respectively. Of the 2355 respondents, 2081 provided a valid manufactured cigarette brand name. The remaining cases were excluded for providing a nonsense answer (6.3%), using roll-your-own tobacco (2.6%), responding with a non-cigarette product (1.3%), or having no preferred brand (1.1%).

Cigarette Design

The sample of current smokers using manufactured cigarettes was 2081 (2016: 1058; 2017: 1023). Drawing on this self-report survey data, the 26 most commonly reported brands of cigarettes were purchased in convenience stores in Buffalo, NY during June-July 2018. Following the ISO 3402:1999, cigarettes were placed in an environmental chamber to be conditioned for a minimum of 48 hours at 22 degree Celsius and 60% relative humidity. Prior to testing, 5 cigarettes were chosen randomly and removed from each pack to be used for physical measurement assessment and data averaged. Length of the entire cigarette, the rod diameter, the filter diameter, tobacco, and the filter itself were measured with digital calipers, and the weight of the filters were obtained using a Mettler-Toledo analytical scale. The tobacco rod was weighed using a halogen moisture analyzer (125 degree Celsius). We also calculated percent tobacco moisture. Filter ventilation (%), the level of dilution of smoke flow through the filter, was determined with a Borgwaldt PV10 (Hauni, Germany) machine using 5 different cigarettes. Design and questionnaire data were available on 1588 participants, and this constituted the final analytical sample.

Data Analysis

We analyzed data with SPSS 21.0 (IBM, Armonk, NY) using analysis of variance, multivariable logistic regressions, and generalized linear models.

RESULTS

Demographics

The study population composition was 45.7% males and 56.3% females. The highest percentage of participants by age group was 18–34 year-olds, with 45.9%. The population was largely non-Hispanic Whites (74.1%); the second largest race/ethnicity group was non-Hispanic Blacks (8.4%). Overall, there were differences in ventilation groups by both categorical ages and sex (p = 0). Across all age ranges, percentage of those smoking low-vented cigarettes was the highest (83% in those less than 18 years of age, 82% in those 18-43 year-olds, and 63% in those older than 35 years of age).

Brands

Among all respondents, the most commonly reported brands were Marlboro (46.9%), Camel (9.2%), Newport (8.6%), Pall Mall (8.5%), Winston (2.1%), Kool (1.9%), L&M (1.9%), and American Spirit (1.8%). Overall, 18% reported using a menthol brand, and 85% reported using king size. Most respondents (72.8%) reported only the brand family (eg, Marlboro, Camel, etc), not the specific sub-brand they might be smoking. Among the respondents who provided a sub-brand descriptor (N = 666), the most commonly reported were light (3.7%), red (1.6%), gold (1.0%), and blue (0.8%). Ventilation levels for the 26 most commonly reported sub-brands of cigarettes were assessed independently. Table 1 shows the filter ventilation levels of the different cigarette brands tested (mean = 15.23%, SD = 10.64, minimum = 0.18, maximum = 57.04).

Table 1.

Cigarette Filter Ventilation Values for Cigarette Brands Tested

Name	N of users	Vent %
Marlboro Red	794	9.8
Camel	182	23.84
Newport Green	160	0.18
Pall Mall Red	119	35.34
Marlboro Gold	106	23.06
Natural American Spirit (Blue)	42	18.68
Winston Red	40	17.88
Marlboro Silver	27	44.98
Marlboro Menthol Green Pack	21	15.96
Marlboro Special Blend Gold Pack	19	35.6
Camel Crush Menthol	16	18.3
Marlboro Black Bold Flavor	11	0.54
Marlboro Special Blend Red Black	11	26.06
Camel Blue	8	32.2
Pall Mall Blue	7	36.5
Newport Red	6	0.36
Camel Crush Menthol Silver	4	33.1
Pall Mall Menthol Green	4	36.66
Natural American Spirit (Green)	2	0.4
Marlboro Black Bold Menthol Flavor	2	0.8
Winston Gold	2	30.88
Natural American Spirit (Yellow)	2	34.94
Newport Menthol Gold	1	40.54
Marlboro Menthol Silver Pack	1	48.84
Pall Mall Orange	1	57.04

Awareness and Understanding

Combining data from the surveys conducted in 2016 and 2017, 43.1% of respondents reported awareness of filter vent holes in the cigarettes that they smoke, with an additional 9.2% responding ‘don’t know’. There was a statistically significant difference by year (2016: 46.0% aware vs 2017: 40.0% aware; p = .003). Younger smokers (18–34: 49.4% vs 35+: 34.1%, p < .001) and men (56.4% vs 31.7% for women; p < .001) were far more likely to report awareness. Non-Hispanic black smokers were least likely to be aware of vents (24.3% vs. 43.2% of Non-Hispanic Whites, 58.0% of Hispanics, and 38.6% of other smokers; p < .001). We asked those who responded ‘yes’ or ‘don’t know’ to awareness of filter ventilation (N = 1088) whether they thought that blocking the holes would make the cigarette taste stronger, milder, or have no effect. Of these, 57.3% reported that blocking would make cigarettes taste stronger, 18.2% milder, 11.3% no effect, and 13.2% ‘don’t know.’ We saw no evidence that this pattern of responding differed across years (p = .336). Younger smokers (59.6% vs 53.0%, p < .001) and men (60.7% vs 52.8%, p < .001) were more likely to report that blocking made their cigarette taste stronger. Combining awareness and understanding of the function of vents, 29.9% answered affirmatively on both items (Awareness + Understanding, A + U). In a multivariable logistic regression model, age and sex remained significant predictors of both awareness only and A + U, while the survey year and race effects were attenuated (Table 2). We found overall differences in awareness of the presence of ventilation holes based on ventilation groups (non-vented, low-vented and high-vented cigarettes; p = 0), but statistically significant differences only found between the non-vented and low-vented group, and then the low-vented and high-vented group (p = 0).

Table 2.

Odds Ratios of Demographics by Awareness and Awareness + Understanding

	Awareness (N = 311)			Awareness + Understanding (N = 420)
	OR	95% CI		OR	95% CI
Cigarettes per day	1.00	0.99	1.02	1.01	1.00	1.03
2016	1.01	0.76	1.33	1.01	1.00	1.02
2017	REF			REF
Age 18–34	1.48	1.09	2.02	0.82	0.63	1.07
Age 35+	REF			REF
Male	2.24	1.69	2.98	2.09	1.56	2.82
Female	REF			REF
Non-Hispanic White	REF			REF
Non-Hispanic Black	1.36	0.68	2.71	1.02	0.51	2.04
Hispanic	1.37	0.86	2.18	1.35	0.88	2.08
Other race/ethnicity	0.87	0.49	1.54	0.45	0.23	0.87
Daily Smoker	1.08	0.72	1.60	1.40	0.94	2.06
Non-daily smoker	REF			REF
Ventilation	1.00	0.98	1.01	1.01	1.00	1.02

Note.

Bolded shows statistical significance of p ≤ .019.

Perceived Risk

We next explored whether filter vent awareness or understanding was related to worry about or perceived risk of lung cancer in the subset where ventilation data were present (Table 3). We found that, adjusted for demographics (age, sex, race/ethnicity) and smoking behaviors (daily/nondaily, cigarettes per day), awareness alone and A + U were each significantly more likely than those unaware to express worry about lung cancer. We found no association between vent awareness and perceived risk of lung cancer. However, higher own-brand ventilation was associated with greater perceived risk of LC. Older smokers were less likely to express worry but more likely to perceive themselves at greater risk than other smokers. We also examined the more generalized perceived risk (PR) measure (which assesses risk relative to a nonsmoker across 9 smoking-related conditions). Adjusted for covariates and ventilation, vent awareness was not significantly related to PR score (p = .248), though own-brand ventilation (OR = 1.003; all ps < .003) was associated with PR score. Perceived risk sum scores also were statistically significantly related to age (OR = 1.073 35+) and sex (OR = 1.06 females).

Table 3.

Odd Ratios of Worry about Lung Cancer and Risk of Lung Cancer Compared to other Smokers

	Worry about LC			Risk of LC compared to other smoker
	OR	95% CI		OR	95% CI
Awareness + Understanding	1.47	1.15	1.87	0.94	0.73	1.20
Aware	1.40	1.08	1.81	1.14	0.87	1.48
Unaware	REF			REF
2016	1.21	0.98	1.48	1.30	1.05	1.60
2017	REF			REF
35+	0.61	0.49	0.77	1.48	1.18	1.86
18–34	REF			REF
Female	1.36	1.10	1.67	1.45	1.17	1.80
Male	REF			REF
Other race/ethnicity	0.67	0.39	1.15	0.91	0.53	1.54
Hispanic	1.08	0.78	1.51	1.07	0.75	1.52
Non-Hispanic Black	1.23	0.80	1.90	1.27	0.82	1.99
Non-Hispanic White	REF			REF
Non-daily smoker	0.88	0.66	1.18	0.56	0.41	0.75
Daily smoker	REF			REF
Cigarettes per day	0.99	0.98	1.01	1.01	1.00	1.02
Ventilation	1.00	0.99	1.01	1.02	1.01	1.03

Note.

Bolded shows statistical significance of p ≤ .015.

We also explored whether participants’ awareness of vents was related to sensory perceptions of smoking their own brand of cigarettes. Awareness was not associated with perception of lightness/intensity or smoothness/harshness, but participants had significantly greater odds of saying they enjoyed the taste of their own brand (Table 4). Older participants were statistically more likely to report that their own cigarettes had differences in smoothness or harshness but were less likely to report that they enjoyed the taste of their cigarettes. Females were more likely to report that their cigarettes differed in smoothness or harshness, while reporting they enjoyed their cigarettes taste more than males reported. Own-brand ventilation was associated with lower perceived intensity and taste enjoyment, and greater perceived smoothness, relative to other brands.

Table 4.

Odd Ratios of Sensory Perceptions

	Compared to other cigarettes on the market, do you think your cigarettes are lighter in taste (1), about the same (2) or more intense in taste (3)?			Compared to other cigarettes on the market, do you think your cigarettes are harsher on your throat (1), about the same (2) or smoother (3) on your throat?			Overall, how much do you enjoy the taste of your cigarettes? (1 = not at all, 2 = somewhat, 3 = moderately, 4 = a lot)
	OR	95% CI		OR	95% CI		OR	95% CI
Awareness + Understanding	0.90	0.68	1.20	0.84	0.63	1.11	1.46	1.14	1.96
Aware	1.08	0.80	1.46	0.92	0.68	1.24	1.37	1.02	1.83
Unaware	REF			REF			REF
2016	0.94	0.74	1.19	1.03	0.81	1.31	1.01	0.80	1.27
2017	REF			REF			REF
35+	1.12	0.87	1.45	1.39	1.08	1.80	0.69	0.54	0.89
18–34	REF			REF			REF
Female	0.84	0.67	1.07	1.38	1.08	1.76	0.65	0.52	0.82
Male	REF			REF			REF
Other race/ethnicity	2.64	1.40	4.97	1.08	0.58	2.04	1.24	0.68	2.25
Hispanic	0.79	0.53	1.18	0.78	0.52	1.18	1.65	1.11	2.46
Non-Hispanic Black	0.99	0.59	1.67	0.85	0.50	1.43	0.52	0.31	0.86
Non-Hispanic White	REF			REF			REF
Cigarettes per day	1.01	1.00	1.03	1.00	0.98	1.01	1.02	1.01	1.03
Ventilation	0.98	0.97	0.99	1.02	1.01	1.03	0.99	0.98	1.00

Note.

Bolded is statistically significant, p is less than or equal to .035.

We obtained a Cigarette Evaluation Scale (CES) measure for those who had smoked a cigarette in the past 3 hours, (Table 5). Those in the A + U category had significantly higher scale values relative to those unaware of vents (Table 5 & Figure 1). In multivariate models, own-brand ventilation was significantly inversely associated with CES sub-scales for satisfaction, aversion, and reward, whereas a marginal relationship was seen for enjoyment, and no statistically significant relationship was seen for craving reduction.

Table 5.

Cigarette Evaluation Scale

	CES-Satisfaction			CES-Reward			CES-Aversion			CES - Enjoyment			CES-Craving Reduction
	B	SE	P	B	SE	P	B	SE	P	B	SE	P	B	SE	P
(Intercept)	5.08	0.13	0	4.46	0.15	0	3.43	0.18	0	4.53	0.18	0	4.90	0.16	0
Aware + Understand	0.23	0.10	.02	0.39	0.11	0	0.89	0.13	0	0.45	0.13	0	0.27	0.11	.02
Aware	0.24	0.12	.02	0.14	0.12	.24	0.45	0.14	0	0.18	0.14	.20	−0.05	0.12	.69
Unaware	REF			REF			REF			REF			REF
2016	0.19	0.08	.02	0.23	0.09	.01	0.11	0.11	.32	0.25	0.11	.02	0.07	0.10	.47
2017	REF			REF			REF			REF			REF
35+	−0.53	0.09	0	−0.97	0.10	0	−1.49	0.20	0	−0.71	0.12	0	−0.25	0.10	.02
18–34	REF			REF			REF			REF			REF
Female	−0.16	0.08	.05	−0.07	0.09	.42	−0.67	0.11	0	−0.36	0.11	0	0.11	0.10	.25
Male	REF			REF			REF			REF			REF
Other race/ethnicity	0.14	0.22	.53	0.11	0.24	.66	−0.25	0.30	.39	0	0.29	.99	0.11	0.26	.67
Hispanic	0.42	0.14	.00	0.53	0.16	.00	0.90	0.19	0	0.42	0.19	.03	−0.08	0.17	.63
Non-Hispanic Black	−0.09	0.19	.65	0.14	0.21	.49	0.15	0.25	.56	−0.14	0.25	.57	0.22	0.22	.31
Non-Hispanic White	REF			REF			REF			REF			REF
Cigarettes per day	0.02	0	0	0.02	0.01	0	0	0.01	.50	0.02	0.01	.01	0.02	0.01	0
Vent	−0.01	.00	.01	−0.01	0	.02	−0.02	.01	.01	−0.01	0.01	.07	0	0	.54
(Scale)	1.68b	0.07		2.03b	0.09		3.04b	0.13		2.88b	0.13		2.30b	0.12

Figure 1.

Cigarette Evaluation Scale Awareness and Understanding

DISCUSSION

Many smokers remain unaware of the presence and function of filter vents in the cigarettes that they smoke. Smokers who are aware of filter ventilation were younger, male, and more concerned about their health. Today’s younger smokers may be more likely to smoke a filtered cigarette that is vented, possibly one of the reasons for a higher awareness. Regardless, the overall levels of smokers’ awareness and understanding of filter ventilation looks to be about the same as reported in studies conducted nearly 20 years ago, still roughly around 40% awareness now as in the Kozlowski et al²³ study in 1996, despite enactment of regulations and programs intended to inform smokers about misleading brand descriptors and the function of filter vents. These efforts have included a 2003 Illinois court ruling labeling light cigarettes a fraud,³⁴ the FTC ruling in 2008 prohibiting the reporting of tar and nicotine levels in advertising and on cigarette packs,³¹ the 2010 regulation banning misleading brand descriptors in advertising and on cigarette packs,¹⁴ and the US District court mandated corrective statements. These instances have all highlighted that light and low tar do not indicate cigarette safety.³⁵

In 2003, Altria implemented package inserts and tear strips on selected brands informing smokers that low tar/light cigarettes did not mean that these cigarettes were safer, although they did not specifically inform consumers about filter ventilation. However, evidence suggests that, at least in the US, removing the descriptors has had little effect on misperceptions, likely because the underlying design feature (ventilation) remains. In addition, packaging has mostly stayed unchanged following removal of the specific terms, with colors and designs remaining exactly the same and color names replacing the misleading descriptor term (ie, Marlboro Light became Marlboro Gold, Salem Lights became Salem Gold Box).

Regarding sensory perceptions, even after adjusting for awareness of vents, demographics, and cigarettes per day, own-brand ventilation was significantly associated with perceptions of lightness, mildness, and smoothness, relative to other brands, as well as lower satisfaction, reward, and aversion from recently smoked cigarettes. This suggests that vents are contributing to the sensory experience and help to explain why bans on misleading descriptors, which are often proxies for ventilation level, often have been ineffective at changing risk perceptions or behaviors over the long term.¹⁴

Awareness and understanding of the function of vents is important. There is suggestive evidence that filter ventilation has increased the risk of the most common type of lung cancer.⁴ Some studies overlook smokers’ awareness and understanding of filter ventilation as a critical component of determining health risk, focusing instead on smoking machine constituent yields, and harmful and potentially harmful constituent (HPHC) values in research.^33,36,37 However, these measures can be misleading because manipulation (even unintentionally) of ventilation holes by smokers can increase machine-measured emission yields in cigarette smoke and harmful constituent exposure. More attention should be paid to informing the public of the presence of deceptive cigarette design and that, due in part to the elasticity of smoking behavior with blocked ventilation holes and/or heavier smoking intensity, exposures do not differ meaningfully across cigarette brands. Early examples of such communications using radio and television messages appeared to produce sustained changes in beliefs.^38,39

Limitations

There are at least 2 limitations related to this study. First, the study design was cross-sectional. Second, data came from a smaller subset of the overall study group. Collecting from a larger sample size might had solidified our results.

IMPLICATIONS FOR TOBACCO REGULATION

Our study reinforces the evidence of the ineffectiveness of simply removing misleading descriptors on packs and in advertising; instead. it argues for informing smokers about filter vents in the cigarettes they smoke.⁴⁰ Ventilation contributes to harms associated with cigarette smoking; yet, many smokers are unaware of ventilation and its function, even when their own brands are vented. However, among those smokers who are aware of vents and understand their function, there appears to be a more accurate perception of risk. This lends support for more direct public education about the use of ventilation and its effects on health, specifically the effects of ventilation on changing smoking behavior and its impact on the health risks from smoking. Whereas this in itself would not be expected to alter behaviors on a large scale, it could serve to bolster public understanding for future regulatory actions, including banning ventilated filters, which may seem counterintuitive to smokers who are unaware of their associated risk.