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. Author manuscript; available in PMC: 2020 Nov 1.
Published in final edited form as: Addict Behav. 2019 Jun 10;98:106020. doi: 10.1016/j.addbeh.2019.06.009

Prevalence and correlates of nicotine and nicotine product perceptions in U.S. young adults, 2016

Andrea C Villanti a,b,*, Shelly Naud c, Julia C West a, Jennifer L Pearson b,d, Olivia A Wackowski e, Raymond S Niaura f, Elizabeth Hair b,g, Jessica M Rath b,g
PMCID: PMC6947657  NIHMSID: NIHMS1063834  PMID: 31238235

Abstract

Introduction:

Nicotine is not a human carcinogen and combustion compounds in tobacco smoke, rather than nicotine, cause tobacco-related cardiovascular disease. Few recent studies examine the public’s beliefs about nicotine in relation to smoking.

Methods:

Participants aged 18–40 (n = 4,091) in Wave 10 (Fall 2016) of the Truth Initiative Young Adult Cohort Study responded to nineteen items on nicotine and nicotine product perceptions, including addictiveness and health harms of nicotine patch/gum and e-cigarettes compared to cigarettes. Analyses conducted in 2018 examined prevalence of perceptions and sociodemographic and tobacco use correlates of selected perceptions.

Results:

The majority of young adults reported that nicotine was responsible for a “relatively” or “very large” part of the health risks (66%) and cancer (60%) caused by smoking. More than half of young adults (55%) believed that nicotine is a cause of cancer. Between 23% and 43% of young adults responded “don’t know” to items on nicotine. Females, blacks, Hispanics, and those with less than some college education were more likely to report true or “don’t know” vs. false to “nicotine is a cause of cancer” and had higher odds of believing that nicotine was responsible for a “relatively” or “very large” part of the health risks of smoking and cancer caused by smoking. Past 30-day tobacco users had lower odds of reporting these beliefs.

Conclusions:

Misperceptions of nicotine are widespread in young adults. Public education is needed to maximize the public health impact of FDA’s required nicotine warning label and proposed nicotine reduction policies.

Keywords: Nicotine, harm perceptions, young adults, smoking, reduced nicotine content

1. Introduction

Smoking accounts for one out of every three cancer deaths in the U.S. (U.S. Department of Health and Human Services, 2014), but authoritative reviews of carcinogens in tobacco and tobacco smoke have not listed nicotine among the carcinogens (IARC Working Group on the Evaluation of Carcinogenic Risks to Humans, 2007, 2012a, 2012b; U.S. Department of Health and Human Services, 2010). Likewise, the 2014 US Surgeon General’s report concluded that combustion compounds in tobacco smoke, rather than nicotine, are the primary contributors to the cardiovascular risk of tobacco use (U.S. Department of Health and Human Services, 2014). As noted by FDA, “Nicotine is, however, responsible for getting smokers addicted to cigarette smoking in the first place…” (Gottlieb & Zeller, 2017).

Recent population data highlight that approximately half (49%) of U.S. adults incorrectly believe that nicotine is responsible for most of the cancer caused by smoking, with an additional 24% unsure of the relationship between nicotine and cancer (O’Brien, Nguyen, Persoskie, & Hoffman, 2017). On average, U.S. adults also report that low nicotine cigarettes are likely to be less harmful and less addictive than a typical cigarette (O’Brien et al., 2017). In a 2015–2016 study, nearly half of adult smokers believed that long-term exposure to very low nicotine content cigarettes was less likely to cause cancer than smoking regular cigarettes (Byron, Jeong, Abrams, & Brewer, 2018). These recent findings are consistent with studies over the past 20 years showing that smokers in the U.S and abroad have little knowledge of nicotine replacement therapy (NRT), and equate the harms of NRT use with the harms of cigarette smoking (Bansal, Cummings, Hyland, & Giovino, 2004; Borrelli & Novak, 2007; Cummings et al., 2004; Etter & Perneger, 2001; Ferguson et al., 2011; Shiffman, Ferguson, Rohay, & Gitchell, 2008; Wikmans & Ramstrom, 2010). Other recent lab studies have shown that reduced nicotine content (RNC) cigarettes are perceived as less harmful than regular cigarettes (Denlinger-Apte, Joel, Strasser, & Donny, 2017; Mercincavage et al., 2017; Pacek et al., 2018). The recent survey studies focus on a small number of measures related to nicotine, failing to provide context for how tobacco users – and the general public – understand nicotine in the context of nicotine replacement products, e-cigarettes, and the wide array of tobacco products now available on the market.

As of August 2018, the Food and Drug Administration’s (FDA) Deeming Rule requires a nicotine warning label (i.e., “This product contains nicotine. Nicotine is an addictive chemical.”) for covered tobacco products. Additionally, in March 2018, FDA issued an Advance Notice of Proposed Rulemaking (ANPRM) to “obtain information for consideration in developing a tobacco product standard to set the maximum nicotine level for cigarettes.” The public health impact of the FDA’s nicotine warnings and proposed nicotine reduction policy hinge on the extent to which tobacco users and non-users understand the harms of nicotine in relation to specific products (e.g., e-cigarettes, NRT, RNC cigarettes) and how this influences individuals’ decisions made regarding product initiation, cessation, product switching, or continued use.

Public education about nicotine will be an essential complement to the FDA’s nicotine policies to move smokers away from combusted tobacco products and prevent non-users from trying nicotine and tobacco products. Identifying the public’s underlying beliefs about nicotine is the first step toward developing such educational efforts; understanding subgroups in which these nicotine misperceptions are more prevalent will guide the tailoring of educational campaigns. Young adults are at increased risk for onset of tobacco use (Thompson, Mowery, Tebes, & McKee, 2018) and have a higher prevalence of current tobacco use than youth and older adults (Kasza et al., 2017). Additionally, youth and young adults who perceive specific tobacco products as less harmful than cigarettes are more likely to try those products (Parker et al., 2018; Villanti, Cobb, Cohn, Williams, & Rath, 2015). As a transitional period in which addiction is most likely to become established, (Sussman & Arnett, 2014) young adulthood is a critical time for intervention to prevent progression to firmly entrenched tobacco use in adulthood and future disease and death (Villanti, Niaura, Abrams, & Mermelstein, 2019). The goal of the current study was to describe the prevalence and correlates of a wide range of survey items on nicotine and nicotine product perceptions in a national sample of U.S. young adults. We had two main study hypotheses:1) adults aged 18–40 will identify nicotine as causing cancer and contributing to “a relatively large part” of health risks and cancer related to cigarette smoking; and 2) adults aged 18–40 will rate nicotine medications (e.g., patches, gum, lozenges) as “about the same” as cigarettes in terms of relative addictiveness, risk of heart attack, and long-term health harms. With respect to correlates, we expected that nicotine and nicotine product perceptions would differed in tobacco users compared to non-users and among non-users, in those susceptible to cigarette smoking. We also hypothesized that social influences would be correlated with young adults’ perceptions of nicotine based on primary socialization theory (Oetting, 1999; Oetting & Donnermeyer, 1998), as well as self-identified smoking status (Hertel & Mermelstein, 2012; Johnson et al., 2018; Villanti et al., 2017). We expected novel items on perceptions of nicotine and nicotine products to provide a more fulsome picture of how young adults perceive nicotine, especially in relationship to e-cigarettes, which have become a prevalent product in the tobacco marketplace.

2. Material and methods

2.1. Study sample

The current study leverages data from 4,091 respondents aged 18–40 in Wave 10 of the Truth Initiative Young Adult Cohort Study (YA Cohort; September-October 2016), a large contemporary cohort of U.S. young adults that includes information on trajectories of smoking behavior. The detailed methods of this study have been described elsewhere (Rath, Villanti, Abrams, & Vallone, 2012). The cohort is comprised of a nationally representative sample of young adults ages 18–34 at study entry drawn from GfK’s KnowledgePanel® which is recruited via address-based sampling to provide a statistically valid representation of the U.S. population, including cell phone-only households. The initial age range for the study was chosen based on previous publications by Truth Initiative researchers demonstrating differences in smoking behavior between younger (18–24) and older (25–34) young adults (Green et al., 2007). The survey was administered online in English and Spanish. The cohort was refreshed at each wave to retain the initial sample size.

The panel recruitment rate (American Association for Public Opinion Research, 2015) was 12.7% for Wave 10. In 64.0% of the identified households, one member completed a core profile survey in which key demographic information was collected (profile rate). At each wave, only one panel member per household was selected at random to be part of the study sample, and no members outside the panel were recruited. The completion rate was 61.5% and the cumulative response rate (a product of these three rates) was 5.0% (Callegaro & DiSogra, 2008). This study was approved by the Chesapeake Institutional Review Board, Inc. (Protocol #20036020). Online consent was collected from participants before survey self-administration.

2.2. Measures

2.2.1. Nicotine and nicotine product perceptions

Nineteen items in Wave 10 of the YA Cohort addressed nicotine and nicotine product perceptions, including addictiveness and health harms, adapted from items used in two previous studies (Cummings et al., 2004; Wikmans & Ramstrom, 2010). Three items assessed nicotine’s role in causing disease (i.e., “Nicotine is a cause of cancer”; “According to you, how large a part of the health risks of cigarette smoking comes from the nicotine itself?”; and “According to you, how large a part of the cancer caused by cigarette smoking comes from the nicotine itself?”). Seven items examined perceived addictiveness of NRT, e-cigarettes, and RNC cigarettes and the likelihood of addiction to these products compared to cigarettes. Eight items asked about the relative harms of NRT and e-cigarette use compared to cigarette smoking. One item asked participants to rank the following as least harmful, moderately harmful, or most harmful to health: 1) nicotine delivered via the patch for cessation of tobacco use; 2) nicotine delivered via e-cigarettes for either cessation or harm reduction; and 3) nicotine delivered via e-cigarettes for purposes other than cessation or harm reduction (i.e., recreational use of e-cigarettes).

2.2.2. Tobacco use

Ever use of cigarettes, traditional cigars, pipes, little cigars/cigarillos/bidis, e-cigarettes, smokeless tobacco, snus, and hookah was assessed among all participants at Wave 10. Past 30-day use was assessed for each product among ever users. Participants reporting past 30-day use of any of these eight products were defined as having any past 30-day tobacco use; participants who never used a tobacco product or reported no past 30-day use of any tobacco product were defined as not having any past 30-day tobacco use.

2.2.3. Correlates

Age, gender, race/ethnicity, education, and household income were collected at each wave of the YA Cohort. Social influences were assessed as peer and parent influence on smoking. Peer influence was assessed by asking how many of one’s four closest friends smoke cigarettes and coded as 0 friends who smoke or 1+ friends who smoke. Parental influence was assessed by asking at study entry whether one or both parents or guardians smoked cigarettes during the respondent’s childhood. Self-identified smoking status was measured using the following item as a correlate in the current study: “Which of the following best describes how you think of yourself?” with response choices of “smoker,” “social smoker,” “occasional smoker,” “ex-smoker,” “someone who tried smoking,” and “nonsmoker.” Categories were collapsed to “smoker,” “social/occasional smoker,” “ex-smoker/tried smoking” and “non-smoker.” Susceptibility to smoking cigarettes in non-past 30-day tobacco users was assessed using the three-item scale developed by Pierce et al. (Choi, Pierce, Gilpin, Farkas, & Berry, 1997; Evans, Farkas, Gilpin, Berry, & Pierce, 1995; Pierce, Choi, Gilpin, Farkas, & Merritt, 1996; Pierce, Distefan, Kaplan, & Gilpin, 2005; John P Pierce, Farkas, Evans, & Gilpin, 1995).

2.3. Statistical analysis

Analyses conducted in 2018 used Stata MP, Version 15.1 and survey weights to account for the sampling design and non-response. Missing data were handled with listwise deletion per Stata’s svy procedures. We calculated weighted prevalence estimates for all nineteen nicotine and nicotine product perception items by any past 30-day tobacco use and separately, by susceptibility to smoking cigarettes among non-past 30-day tobacco users and identified differences using a design-based Fstatistic. We further examined the correlations between sociodemographic variables, peer and parent cigarette smoking, self-identified smoking status, any past 30-day tobacco use and responses to the three items on nicotine’s role in causing disease in bivariate and multivariable analyses. Parent cigarette smoking was excluded from further analyses due to the extent of missing data. We explored the relationship between these covariates and a fourth outcome (ranking of the uses of nicotine) in multiple linear regression models.

3. Results

The study sample was composed of 4,091 U.S. young adults aged 18–40, of which 23% were aged 18–24, 57% were aged 25–34, and 20% were aged 35–40 (Table 1). Over half of the sample was non-Hispanic white (56%), 13% was non-Hispanic black, 22% was Hispanic, and 9% reported other race. Approximately half were female (51%) and the majority had completed at least some college education (67%). There were significant differences by past 30-day tobacco use status for all covariates, with higher prevalence of past 30-day tobacco use seen in those aged 25–34, non-Hispanic whites, males, those with less than some college education, those with lower income, those with smoking peers or parents, and those self-identifying as a “smoker” or “social/occasional smoker.” In the sample of non-past 30-day tobacco users, 15% were susceptible to cigarette smoking.

Table 1.

Participant characteristics by any past 30-day tobacco usea

Any past 30-day tobacco use
No (n = 3,232) Yes (n = 860) Total (n = 4,091) p-Value
Weighted n % Weighted n % Weighted n %
Age group 0.002
 18–24 774 23.9 156 18.1 929 22.7
 25–34 1,784 55.2 704 62.5 2,321 56.7
 35–40 674 20.9 537 19.4 841 20.5
Race 0.007
 White, non-Hispanic 1,801 55.7 503 58.5 2,304 56.3
 Black, non-Hispanic 378 11.7 136 15.8 514 12.6
 Other, non-Hispanic 317 9.8 66 7.7 383 9.4
 Hispanic 735 22.8 155 18.0 891 21.8
Gender < 0.001
 Male 1,509 46.7 510 59.3 2,019 49.3
 Female 1,723 53.3 350 40.7 2,073 50.7
 Education completed < 0.001
 Less than high school 246 7.6 119 13.9 365 8.9
 High school 714 22.1 254 29.6 969 23.7
 Some college or greater 2,271 70.3 486 56.6 2,758 67.4
Annual household income < 0.001
 Less than $10,000 357 11.0 159 18.5 516 12.6
 $10,000–$24,999 424 13.1 145 16.8 569 13.9
 $25,000–$49,999 813 25.2 217 25.2 1,030 25.2
 $50,000–$99,999 1,056 32.7 218 25.4 1,274 31.2
 More than $100,000 581 18.0 120 14.0 702 17.2
Peer cigarette smoking, 1 + vs. 0 < 0.001
 0 2,047 64.8 143 16.9 2,190 54.6
 1 + 1,114 35.2 704 83.1 1,818 45.4
Parent cigarette smoking, 1 + vs. 0) < 0.001
 0 1,484 63.2 262 41.4 1,746 58.6
 1 + 865 36.8 371 58.6 1,236 41.4
Self-identified smoking description < 0.001
 Smoker 10 0.3 337 39.4 347 8.6
 Social or occasional smoker 85 2.7 287 33.6 372 9.2
 Ex-smoker/tried smoking 542 17.1 141 16.5 683 16.9
 Non-smoker 2,539 80.0 90 10.5 2,629 65.2
Susceptible to tobacco use -
 No 2,706 85.1 - - 2,706 85.1
 Yes 474 14.9 - - 474 14.9
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Boldface indicates statistical significance (p < 0.05) calculated from a design-based F statistic.

a

Missing data: peer smoking (n = 67, 1.6%), parent smoking (n = 1,110, 27.3%), self-identified smoking status (n = 50, 1.2%), susceptible to tobacco use (n = 45, 1.1%)

3.1. Prevalence of nicotine perceptions

Table 2 presents responses to nicotine and nicotine product perception items by any past 30-day tobacco use. Overall, 55% of young adults believed that nicotine is a cause of cancer, with an additional 24% reporting that they did not know. More than 60% of respondents believed that a relatively or very large part of the health risks (66%) or cancer (60%) caused by smoking come from the nicotine, in line with our first hypothesis.

Table 2.

Prevalence of nicotine and nicotine product perception items by any past 30-day tobacco use.a

Any past 30-day tobacco use
No (n = 3232) Yes (n = 860) Total (n = 4091) p-Value
Weighted % Weighted % Weighted %
Nicotine perceptions
Nicotine is a cause of cancer. < 0.001
 True 56.0 50.4 54.8
 False 18.9 28.8 21.0
 Don’t know 25.1 20.8 24.2
According to you, how large a part of the health risks of cigarette smoking come from the nicotine itself? < 0.001
 None or a very small part 5.4 10.4 6.5
 A relatively small part 25.0 37.9 27.8
 A relatively large part 42.3 37.0 41.2
 A very large part or all 27.2 14.7 24.6
According to you, how large a part of the cancer caused by cigarette smoking comes from the nicotine itself? < 0.001
 None or a very small part 7.4 13.5 8.7
 A relatively small part 29.2 37.1 30.9
 A relatively large part 36.4 31.9 35.4
 A very large part or all 27.0 17.5 25.0
Nicotine product perceptions
Relative harm: e-cigarettes vs. cigarettes 0.001
 Less harmful 36.1 45.0 38.0
 About the same 45.9 40.0 44.7
 More harmful 18.0 14.9 17.3
Relative harm: Nicotine products (like gum, patches, or lozenges) vs. cigarettes 0.002
 Less harmful 42.2 50.4 43.9
 About the same 40.6 35.2 39.5
 More harmful 17.2 14.5 16.6
Long term use of nicotine from patches or gums is almost as harmful to health as cigarette smoking. < 0.001
 True 38.7 37.4 38.4
 False 16.1 26.6 18.3
 Don’t know 45.3 36.0 43.3
Long term use of e-cigarettes is almost as harmful to health as cigarette smoking. < 0.001
 True 47.5 39.8 45.9
 False 11.9 23.9 14.5
 Don’t know 40.6 36.3 39.7
Would using nicotine gum or patches be more likely, about the same, or less likely to cause YOU to develop cancer as regular cigarettes? 0.089
 More likely 9.4 7.1 8.9
 About the same 51.7 50.0 51.3
 Less likely 38.9 42.9 39.8
Would using electronic cigarettes (e-cigarettes) be more likely, about the same or less likely to cause YOU to develop cancer as regular cigarettes? < 0.001
 More likely 9.0 8.5 8.9
 About the same 61.8 52.4 59.8
 Less likely 29.2 39.1 31.3
Are nicotine patches more likely, about the same, or less likely to cause someone to have a heart attack as cigarettes? 0.001
 More likely 8.1 6.6 7.8
 About the same 56.6 50.0 55.2
 Less likely 35.3 43.4 37.1
Are electronic cigarettes (e-cigarettes) more likely, about the same, or less likely to cause someone to have a heart attack as cigarettes? < 0.001
 More likely 8.2 7.6 8.1
 About the same 63.2 52.1 60.8
 Less likely 28.6 40.3 31.1
Mean ranking of uses of nicotine (1 = least harmful, 3 = most harmful)
 Nicotine patch for cessation of tobacco use 1.66 1.83 1.70 < 0.001
 E-cigarettes for either cessation or harm reduction 2.03 2.02 2.02 0.74
 E-cigarettes for other purposes 2.31 2.16 2.28 < 0.001
It is easy to get addicted to nicotine gum. < 0.001
 True 49.5 44.2 48.3
 False 8.0 18.0 10.1
 Don’t know 42.6 37.8 41.6
It is easy to get addicted to e-cigarettes. < 0.001
 True 55.7 51.9 54.9
 False 7.0 17.6 9.3
 Don’t know 37.2 30.4 35.8
The claim that a cigarette brand is low in nicotine means that it is less addictive. 0.002
 True 17.2 14.5 16.6
 False 58.5 66.5 60.2
 Don’t know 24.4 19.0 23.2
The claim that an e-cigarette brand is low in nicotine means that it is less addictive. < 0.001
 True 18.5 20.1 18.9
 False 46.8 53.9 48.3
 Don’t know 34.7 25.9 32.8
Are nicotine patches more likely, about the same, or less likely to cause someone to become addicted as regular cigarettes? 0.004
 More likely 7.0 10.2 7.7
 About the same 55.0 48.3 53.6
 Less likely 38.0 41.4 38.7
Is nicotine gum more likely, about the same, or less likely to cause someone to become addicted as regular cigarettes? 0.13
 More likely 7.6 6.8 7.4
 About the same 55.1 51.3 54.3
 Less likely 37.3 42.0 38.3
Are electronic cigarettes (e-cigarettes) more likely, about the same, or less likely to cause someone to become addicted as regular cigarettes? < 0.001
 More likely 10.6 10.5 10.6
 About the same 67.8 57.4 65.6
 Less likely 21.6 32.1 23.9
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Boldface indicates statistical significance (p < 0.05) calculated from a design-based F statistic.

a

Missingness ranges from 1.8% to 5.0% across items.

Per our exploratory analyses regarding tobacco use status and susceptibility to smoking, past 30-day tobacco use was correlated with nicotine perceptions. Compared to non-past 30-day tobacco users, past 30-day tobacco users were approximately half as likely to report “true” (vs. false, RRR = 0.47; Table 3) or “don’t know” (vs. false, RRR = 0.53) to nicotine is a cause of cancer and that nicotine was responsible for a relatively/very large part of the health risks (vs. small/none, AOR =0.42) or cancer (AOR = 0.51) caused by smoking (Table 4). There were few correlations, however, between susceptibility to smoking and nicotine perceptions among non-tobacco users. Those susceptible to smoking cigarettes had lower odds of perceiving that a large part of the health risks (OR = 0.76) of smoking come from the nicotine compared to those who were non-susceptible (Table S1).

Table 3.

Nicotine perceptions: “Nicotine is a cause of cancer”, weighted prevalence and adjusted relative risk ratios.

Nicotine is a cause of cancer
False (Ref.) True True vs. false Don’t know Don’t know vs. false
% % RRRa 95% CI % RRRa 95% CI
Age group
18 – 24 19.4 52.3 0.85 (0.64 – 1.13) 28.3 1.17 (0.84 – 1.63)
25 – 34 21.8 54.7 0.90 (0.72 – 1.13) 23.4 1.00 (0.75 – 1.33)
35 – 40 20.6 57.6 Ref. 21.8 Ref.
Race/ethnicity
White, non-Hispanic 25.6 52.5 Ref. 21.9 Ref.
Black, non-Hispanic 12.2 57.7 2.11** (1.41 – 3.15) 30.2 2.52** (1.62 – 3.91)
Other, non-Hispanic 20.3 58.2 1.41* (1.00 – 2.00) 21.5 1.27 (0.84 – 1.91)
Hispanic 14.6 57.7 1.67** (1.27 – 2.19) 27.8 1.90** (1.39 – 2.59)
Gender
Male 24.3 51.5 Ref. 24.2 Ref.
Female 17.8 58.0 1.46** (1.02 – 1.75) 24.2 1.28* (1.04 – 1.59)
Education completed
Less than high school 13.1 62.5 1.95* (1.15 – 3.31) 24.4 1.62 (0.88 – 3.00)
High school 15.1 57.9 1.70** (1.30 – 2.22) 27.0 1.65** (1.23 – 2.23)
Some college or greater 24.1 52.7 Ref. 23.2 Ref.
Annual household income
Less than $10,000 17.0 54.1 1.05 (0.73 – 1.51) 28.8 1.36 (0.89 – 2.06)
$10,000–$24,999 16.9 55.7 1.21 (0.87 – 1.70) 27.4 1.41 (0.96 – 2.06)
$25,000–$49,999 18.0 57.9 1.24 (0.97 – 1.59) 24.1 1.19 (0.89 – 1.59)
$50,000–$99,999 24.0 53.4 Ref. 22.6 Ref.
More than $100,000 26.4 52.3 0.94 (0.74 – 1.18) 21.3 0.88 (0.66 – 1.17)
Peer cigarette smoking
0 peers 20.2 54.2 Ref. 25.6 Ref.
1+ peers 22.2 55.8 0.97 (0.79 – 1.19) 21.9 0.79 (0.62 – 1.01)
Self-identified smoking status
Smoker 24.2 55.6 1.38 (0.84 – 2.26) 20.1 1.11 (0.61 – 2.03)
Social or occasional smoker 27.2 51.1 1.09 (0.68 – 1.73) 21.7 0.95 (0.55 – 1.64)
Ex-smoker/tried smoking 23.9 52.4 0.88 (0.68 – 1.13) 23.7 0.95 (0.71 – 1.28)
Non-smoker 19.0 55.9 Ref. 25.2 Ref.
Any past 30-day tobacco use
No 18.9 56.0 Ref. 25.1 Ref.
Yes 28.8 50.4 0.47** (0.33 – 0.68) 20.8 0.53** (0.34 – 0.82)
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Boldface indicates statistical significance (p < 0.05).

*

p < 0.05

**

p < 0.001

a

Relative risk ratio (RRR) from multivariable multinomial logistic regression model controlling for all variables in the model.

Table 4.

Nicotine perceptions: “Nicotine’s role in health risks”, weighted prevalence and adjusted odds ratios

According to you, how large a part of the health risks of cigarette smoking come from nicotine? According to you, how large a part of the cancer caused by cigarette smoking comes from the nicotine?
Relatively large part/A very large part or all (vs. small part/none) Relatively large part/A very large part or all (vs. small part/none)
% AORa 95% CI % AORa 95% CI
Age group
18 – 24 67.8 0.90 (0.71 – 1.15) 61.6 0.89 (0.71 – 1.12)
25 – 34 64.1 0.84 (0.69 – 1.03) 59.3 0.90 (0.75 – 1.09)
35 – 40 68.1 Ref. 61.9 Ref.
Race/ethnicity
White, non-Hispanic 60.7 Ref. 54.2 Ref.
Black, non-Hispanic 72.8 1.66** (1.24 – 2.23) 68.0 1.67** (1.26 – 2.23)
Other, non-Hispanic 65.4 1.25 (0.92 – 1.68) 57.8 1.19 (0.90 – 1.59)
Hispanic 75.0 1.68** (1.35 – 2.09) 73.1 1.98** (1.59 – 2.46)
Gender
Male 61.1 Ref. 55.9 Ref.
Female 70.3 1.42** (1.22 – 1.66) 64.7 1.40** (1.20 – 1.63)
Education completed
Less than high school 75.5 1.88** (1.23 – 2.87) 69.1 1.54* (1.02 – 2.34)
High school 70.2 1.41** (1.14 – 1.74) 69.3 1.67** (1.35 – 2.06)
Some college or greater 63.0 Ref. 56.1 Ref.
Annual household income
Less than $10,000 63.5 0.81 (0.61 – 1.09) 62.8 0.98 (0.73 – 1.32)
$10,000–124,999 71.9 1.31 (0.99 – 1.72) 68.0 1.34* (1.02 – 1.76)
$25,000–$49,999 70.5 1.26* (1.03 – 1.55) 64.1 1.20 (0.98 – 1.46)
$50,000–$99,999 63.2 Ref. 56.5 Ref.
More than $100,000 60.2 0.92 (0.75 – 1.13) 54.0 0.96 (0.79 – 1.18)
Peer cigarette smoking
0 peers 67.8 60.7
1+ peers 63.5 0.97 (0.82 – 1.16) 60.0 1.06 (0.89 – 1.26)
Self-identified smoking status
Smoker 56.0 1.16 (0.74 – 1.81) 52.9 1.07 (0.69 – 1.65)
Social or occasional smoker 55.7 1.02 (0.69 – 1.52) 52.5 0.94 (0.64 – 1.38)
Ex-smoker/tried smoking 62.5 0.85 (0.69 – 1.05) 57.2 0.86 (0.69 – 1.05)
Non-smoker 69.5 63.4
Any past 30-day tobacco use
No 69.6 Ref. 63.4 Ref.
Yes 51.7 0.42** (0.30 – 0.58) 49.4 0.51** (0.37 – 0.69)
Open in a new tab

boldface indicates statistical significance (p < 0.05).

*

p < 0.05

**

p < 0.001

a

Adjusted Odds Ratio (AOR) from multivariable logistic regression models controlling for all variables in the model.

3.2. Prevalence of nicotine product perceptions

With respect to our second hypothesis, approximately 44% of young adults perceived that nicotine replacement therapy products (like gum, patches, or lozenges) were less harmful to health than cigarettes, with 39% reporting that they were “about the same” as cigarettes (Table 2). These were consistent with perceptions that long-term use of nicotine from patches or gums (38%) or e-cigarettes (46%) is almost as harmful to health as smoking, though approximately 40% responded “don’t know” to these items. More than half of young adults perceived that nicotine products and e-cigarettes are about as likely to cause cancer and heart attack as cigarettes. Thirty-eight percent (38%) of young adults perceived that e-cigarettes were less harmful to health than cigarettes and 45% that they were about as harmful as cigarettes. Mean ranking of uses of nicotine showed that young adults perceived the nicotine patch for cessation of tobacco use as least harmful, e-cigarettes for either cessation or harm reduction as intermediate, and e-cigarettes for other purposes as most harmful.

Approximately half of young adults perceive that it is easy to get addicted to nicotine gum (48%) or e-cigarettes (55%), with a sizable proportion reporting “don’t know” to these items (nicotine gum, 42%;e-cigarettes, 36%). Approximately half reported that the claim that a cigarette (60%) or e-cigarette (48%) brand is low in nicotine means that it is less addictive was false; again, a large proportion responded “don’t know” to this statement (23% cigarette; 33% e-cigarette). More than half of participants responded that nicotine patches (54%), nicotine gum (54%), and e-cigarettes (66%) were as likely to cause someone to become addicted as cigarettes.

Past 30-day tobacco users generally reported that nicotine was less harmful than non-past 30-day users. Relative likelihood of addiction to nicotine gum (p = 0.13) and cancer from nicotine gum or patches (p =0.089) compared to cigarettes did not differ by past 30-day tobacco use status. Additionally, mean ranking of e-cigarettes for either cessation or harm reduction did not differ by group (p = 0.74). There were few differences in nicotine perceptions by susceptibility to smoking cigarettes among non-past 30-day tobacco users. Those susceptible to smoking cigarettes had lower odds of responding “true” (OR = 0.53) or “don’t know” (OR = 0.46) than “false” to the statement “it is easy to get addicted to e-cigarettes” (Table S1).

3.3. Correlates of nicotine perceptions

In bivariate analyses, age, race/ethnicity, gender, education, income, and self-identified smoking status were correlated with the three outcome variables (nicotine is a cause of cancer, health risks of smoking come from nicotine, cancer caused by smoking comes from nicotine). Compared to those without smoking peers, a smaller proportion of participants with one or more close friends who smoke responded that a large part of the health risks of smoking come from nicotine (63% vs. 68%, p=0.011) or “don’t know” to nicotine is a cause of cancer (vs. false: 22% vs. 26%, p = 0.02). Peer smoking and self-identified smoking status did not remain significant correlates of the outcomes in multivariable analyses.

Females, non-Hispanic blacks, Hispanics, and those with less than a college education had a higher odds of reporting “true” or “don’t know” to nicotine is a cause of cancer (vs. false; Table 3) and reporting that a relatively or very large part of the health risks or cancer caused by smoking comes from the nicotine (vs. small/none; Table 4). Specific household income categories were correlated with reporting that a relatively/very large part of the health risks ($25,000-$49,999 vs. $50,000-$99,999, AOR = 1.25) or cancer ($10,000-$24,999 vs. $50,000-$99,999, AOR = 1.35) caused by smoking come from the nicotine, but there was not a significant correlation between income and reporting that nicotine was a cause of cancer. Similarly, those reporting other race were more likely to respond “true” that nicotine was a cause of cancer than “false” (AOR = 1.42).

Race/ethnicity, education, income and past 30-day tobacco use were correlated with mean rankings of the use of nicotine that also adjusted for age and gender (Table S2). Non-Hispanic blacks, those of other race, and Hispanics (vs. non-Hispanic whites), those with less than a high school education (vs. at least some college), those with annual household income less than $10,000 (vs. $50,000-$99,999) had higher mean rankings of nicotine patch for cessation (i.e., more harmful) and lower mean rankings for using e-cigarettes for other purposes (i.e., less harmful). Respondents with smoking peers also had lower mean rankings for using e-cigarettes for other purposes (b = −0.072).

4. Discussion

The current study presents findings from a large number of novel items on nicotine, NRT and e-cigarette perceptions in a national sample of adults aged 18–40. Consistent with our first study hypothesis, the majority of young adults incorrectly believe that nicotine is a cause of cancer (55%) and that nicotine is responsible for a relatively or very large part of the health risks (66%) of smoking and cancer (60%) caused by smoking. Incorrect beliefs about nicotine as a cause of cancer or as responsible for the health risks and cancer caused by smoking are more prevalent in non-past 30-day tobacco users and in females (vs. males), blacks and Hispanics (vs. whites), and those with less than some college education (vs. at least some college). In addition, when offered the response option “don’t know,” 23% to 43% of young adults were unsure about the addiction or health risks of nicotine products, including e-cigarettes. Variables capturing social influences on tobacco use were not correlated with these beliefs in multivariable models. These findings underscore pervasive misperceptions and lack of information in the general population about nicotine as a tobacco constituent. They may also raise concerns that FDA warning labels about nicotine that address addiction, but not health harms of nicotine, may inadvertently reinforce misperceptions that nicotine is the most harmful constituent in these products, although one recent study with young adults found no effect of e-cigarette nicotine warning messages on nicotine misperceptions (Wackowski et al., 2019).

Overall, young adults perceived nicotine replacement products (e.g., gum, patches, lozenges) as less harmful to health relative to cigarettes than e-cigarettes versus cigarettes. Also consistent with our second study hypothesis, more than 50% of respondents, including past 30-day tobacco users, perceived nicotine gum and patch to be as harmful or more harmful than cigarettes to overall health and specifically, to causing cancer or heart attack. Nicotine misperceptions have been identified as a barrier to NRT use among smokers (Bansal et al., 2004) and earlier work has shown that adult smokers with incorrect beliefs about NRT would be receptive to scientific information to correct their misperceptions and make them more likely to use it in a quit attempt (Ferguson et al., 2011). While there are few studies on changes in perceptions of NRT over the past decade, perceptions of e-cigarettes as less harmful than cigarettes have declined since 2010 (Brose, Brown, Hitchman, & McNeill, 2015; Huang et al., 2019; Huerta, Walker, Mullen, Johnson, & Ford, 2017; Majeed et al., 2017; Tan & Bigman, 2014) and “don’t know” responses have declined in recent years as well (Majeed et al., 2017). This is in contrast to recent evidence syntheses noting greater exposure to toxic substances in cigarettes than e-cigarettes (McNeill, Brose, Calder, Bauld, & Robson, 2018; National Academies of Sciences, Engineering, and Medicine, 2018). Whereas data support that misperceptions of NRT limit its use by smokers, (Bansal et al., 2004) the extent to which misperceptions about nicotine limit or facilitate e-cigarette use is unknown. Additionally, only 17% of the sample believed that the claim that a cigarette brand is low in nicotine means that it is less addictive; if the goal of a nicotine reduction policy is to reduce the addictiveness of combustible cigarettes, education will be needed to align the public’s understanding of the policy and the relationship between nicotine content and addictiveness in cigarettes.

Strengths of the current study include the use of a national sample of young adults and the range of items on perceptions of addictiveness and harms of nicotine, NRT, and e-cigarettes. While the study is limited by a low cumulative response rate, it is similar to other health studies that have relied on KnowledgePanel (Fowler Jr., Gerstein, & Barry, 2013; Grande, Mitra, Shah, Wan, & Asch, 2013; Kumar, Quinn, Kim, Daniel, & Freimuth, 2012; Rhodes, Radecki Breitkopf, Ziegenfuss, Jenkins, & Vachon, 2015). Additionally, the prevalence of responses to the “nicotine is a cause of cancer” item in this sample is consistent with another national sample (O’Brien et al., 2017), supporting external validity of the study findings. One potential limitation of the study is the inconsistent inclusion of a “don’t know” option across all items; it is unclear whether participants would have responded differently to relative harm items had that been an option.

5. Conclusions

Nicotine use is not without harms and should not be encouraged among non-users; however, as acknowledged by the FDA, there is continuum of risk across tobacco products and nicotine is “most harmful when delivered through smoke particles in combustible cigarettes” (U.S. Food and Drug Administration, 2017). This study highlights widespread misperceptions equating the risks of nicotine, NRT, and e-cigarettes with cigarettes in young adults and greater misperceptions of the health risks of nicotine in female, non-white and less educated respondents.

Comprehensive tobacco control programs that educate consumers about risks and/or benefits of a range of tobacco products have lagged behind the rapid proliferation of products in the U.S. market. Communicating about the risks of smoking separate from the risks of nicotine will be essential to maximizing the public health benefit of FDA’s warning labels on nicotine and the proposed policy on nicotine reduction in combustible cigarettes. Findings from this study highlight that health harms of nicotine, relative harms of NRT and cigarettes, and the likely impact of reduced nicotine content cigarettes on addiction and thus, uptake and cessation of smoking, are candidate perceptions to be targeted in public education efforts. Pilot work suggests that a brief nicotine messaging intervention can reduce misperceptions about nicotine, NRT, RNC cigarettes, and e-cigarettes in the short-term (Villanti et al., 2019), but future studies are needed to develop and test these types of messages, ensuring that they produce the intended impact on nicotine and tobacco-related beliefs and behaviors in the longer-term.

Supplementary Material

Supplement

HIGHLIGHTS.

  • More than half of young adults believe that nicotine is a cause of cancer.

  • Many equate the risks of nicotine, NRT, and e-cigarettes with cigarettes.

  • Nicotine is perceived as responsible for smoking-related health risks and cancer.

  • Past 30-day tobacco users had lower odds of reporting these misperceptions.

  • Some subgroups report greater misperceptions of the health risks of nicotine.

Role of funding sources

Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under Award Number R03CA212694. ACV and JCW also received support from the Centers of Biomedical Research Excellence P20GM103644 award from the National Institute of General Medical Sciences of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

Conflict of interests

RSN receives funding from the FDA Center for Tobacco Products via contractual mechanisms with Westat and the NIH. Within the past three years, he has served as a paid consultant to the Government of Canada and has received an honorarium for a virtual meeting from Pfizer. The authors have no other conflicts to disclose. No financial disclosures were reported by the authors of this paper.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.org/10.1016/j.addbeh.2019.06.009.

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