Abstract
Introduction:
Polytobacco use and experimentation is common among young adults. Additional research is needed to determine how these patterns of use impact perceptions of tobacco-related harm and risk. The current study examined whether a relationship exists between an increased number of tobacco products used and decreases in perceptions of harmfulness and health risk.
Method:
Participants (N = 792) completed a survey assessing current/lifetime tobacco use, perceived absolute harmfulness of tobacco/nicotine products and perceived health risk of smoking. For some analyses, participants were grouped by polytobacco use status.
Results:
Among participants who ever tried a tobacco product, a greater number of products tried was associated with lower perceptions of harm (all p < .05). For e-cigarettes and hookah, nonusers rated tobacco products as more harmful compared to single product, dual, and poly users (all p < .05). Number of products tried predicted perceived harmfulness above and beyond demographic characteristics and polytobacco use status across all products. Similarly, number of products tried predicted perceived health risk above and beyond demographic characteristics and polytobacco use status for both lung cancer and heart disease risk.
Discussion:
Trying a greater number of tobacco products is associated with lower perceived harmfulness of tobacco products. Prospective studies are needed to determine if experimentation with more tobacco products leads to reductions in perceived risk of tobacco use and subsequent sustained use of tobacco.
1. Introduction
Young adults (aged 18–24) report the highest prevalence of any past 30-day tobacco use, with more than twofold higher past 30-day use of e-cigarettes, cigarillos, hookah, filtered cigars, and snus than adults over 25 (Kasza et al., 2017). Cross-sectional and prospective studies among young adults show lower perceptions of harm of certain tobacco products (e.g., e-cigarettes, hookah) is correlated with general use of those products (Villanti, Cobb, Cohn, Williams, & Rath, 2015; Wackowski & Delnevo, 2016) and predict subsequent tobacco use behavior (Choi & Forster, 2014; Villanti et al., 2015). However, these studies are limited in scope and address only the relationship between harm perceptions for individual tobacco products [e-cigarettes (Choi & Forster, 2014) and hookah (Villanti et al., 2015)] and later trial of that product. Moreover, youth data suggest dual and polytobacco users, compared to single product users, are less likely to acknowledge tobacco-related harms (El-Toukhy & Choi, 2016). However, research examining polytobacco use (i.e., use of three or more tobacco/nicotine products), and its association with harm perceptions is limited.
As of 2013–2014, 38% of U.S. adult tobacco users were dual or polytobacco users (Kasza et al., 2017) and young adults have been shown to be more likely to use multiple products than older adults (Fix et al., 2014; Lee, Hebert, Nonnemaker, & Kim, 2014; Sung, Wang, Yao, Lightwood, & Max, 2016). However, few studies have investigated what mechanisms lead to the use of more products. It is possible that as the number of products used/tried increases, individuals habituate to the harms associated with each tried product as well as other products, leading to increased use. One mechanism used to describe this phenomenon is acquired capability for tobacco use (Meier, Tackett, Miller, Grant, & Wagener, 2015). This mechanism borrows from the psychological literature (Van Orden et al., 2010) and asserts that use of one or more tobacco product(s) may facilitate use of other tobacco products via decreased perceived harmfulness.
The current study examines a) use patterns, b) perceptions of absolute (e.g., overall health) harmfulness, and c) perceptions of health risk associated with tobacco/nicotine products (e.g., risk of heart problems) among current non-users of tobacco/nicotine, single product users, dual users, and polytobacco users. It is hypothesized that nonusers perceive nicotine/tobacco products as most harmful, followed by single product users, dual users, and lastly, poly users (least harmful perceptions). We hypothesize this pattern will be consistent for perceived harmfulness of products and perceived health risk of smoking for smokers but not non-smokers. We further hypothesize that the number of products tried will predict perceived product harmfulness and perceived risk above and beyond tobacco use status.
2. Method
2.1. Participants and procedure
A convenience sample of undergraduate students (N = 792) at a large, Midwestern university completed an online survey from fall 2012 to spring 2013. Participants were recruited using the university’s online subject pool primarily comprised of students in introductory psychology and speech courses. Participants self-selected into the study from a list of other studies. Following completion of informed consent, participants completed a secure online survey. Participants were compensated with credit to be applied to their course. Procedures were approved by the university’s Institutional Review Board.
2.2. Measures
2.2.1. Tobacco use
Current and past use of tobacco/nicotine products was assessed using the item, “Please select which answer best describes your experience with the following products.” Response options were “never tried – not even once,” “tried it before,” “occasionally use,” and “use daily.” Products assessed included smokeless tobacco (SLT), snus, roll-your-own cigarettes, hookah, e-cigarettes, and combustible tobacco cigarettes. For some analyses, participants were grouped by polytobacco use status based on responses to tobacco use variables. Specifically, participants who reported occasional or daily use of a nicotine/tobacco product were classified as current users. Participants who denied current use of any products were classified as “nonusers”, while those who reported current use of one product were classified as “single product users”, those who reported current use of two products were classified as “dual users”, and participants who reported current use of three or more products were classified as “poly users”. The same current and past tobacco/nicotine items were used to assess the number of unique tobacco/nicotine products participants had ever used. Participants who reported any response other than “never tried – not even once” were considered ever users of the product. The number of products ever used was summed to create a total number of products tried variable. Products assessed included SLT, dissolvables, snus, roll-your-own cigarettes, hookah, e-cigarettes, and combustible cigarettes. Therefore, the range for this item was from 0 to 7 products tried.
2.2.2. Absolute harmfulness of tobacco/nicotine products
Products assessed included cigarettes, smokeless tobacco, hookah, e-cigarettes, and snus. To assess perceived absolute harmfulness of various tobacco/nicotine products participants rated each product on a scale from 0 (“not at all harmful”) to 10 (“extremely harmful”) for the item, “How harmful do you think the following products are to your health?”
2.2.3. Health risk of smoking
Perceived health risk associated with smoking among smokers and nonsmokers was measured via questions adapted from Viscusi, 1990. First, participants responded to the questions, “Out of every 100 cigarette smokers/nonsmokers, how many do you think will get lung cancer?” and “Out of every 100 cigarette smokers/nonsmokers, how many do you think will experience heart problems?”
2.3. Statistical analysis
One-way analyses of covariance (ANCOVA) controlling for age, gender, and ethnicity were used to examine differences between tobacco use groups’ (i.e., nonusers vs. single product users vs. dual users vs. poly users) perceptions of harm and health risk associated with being a smoker. Tukey’s post hoc comparisons were conducted for all significant omnibus tests. A series of hierarchical regressions examined whether the number of products tried was associated with perceived product harmfulness and risk perceptions above and beyond demographic variables (age, gender, and ethnicity; Step 1) and polytobacco use status (Step 2). All analyses were conducted using IBM SPSS v24.
3. Results
3.1. Participant demographics
The majority of participants were female (n = 538; 67.9%), underclassmen (freshmen/sophomores; n = 645; 81.5%), with a mean age of 19.64 (SD = 2.84). The majority of participants identified as Caucasian (n = 598; 75.5%) followed by multiracial (n = 49; 6.2%), Native American (n = 48; 6.1), African American (n = 40; 5.1%), Hispanic (n = 37; 4.7%), Asian (n = 18; 2.3%), and other (n = 2; 0.3%). Among current users, the most commonly used product was hookah (n = 118; 60.2%), followed by combustible cigarettes (n = 79; 40.4%), e-cigarettes (n = 53; 27.0%), SLT (n = 52; 26.6%), roll-your-own cigarettes (n = 14; 7.1%), dissolvables (n = 13; 6.6%), and snus (n = 12; 6.1%). Overall, participants reported ever using 1.5 (SD = 1.9, range = 0–7) unique tobacco/nicotine products while current users reported ever using 3.7 (SD = 1.7) unique products. The majority of participants were classified as nonusers (n = 596, 75%), while 14.3% (n = 113) were single product users, 6.2% (n = 49) were dual users, and 4.3% (n = 34) reported polytobacco use. Among those that reported use of at least two products, hookah was the most common product (n = 62; 74.7%) followed by cigarettes (n = 55; 66.3%), and e-cigarettes (n = 43; 51.8%).
3.2. Perceived absolute harmfulness
Significant differences emerged between tobacco use groups (nonusers vs. single product users vs. dual users vs. poly users) on ratings of absolute harmfulness of e-cigarettes and hookah. (all p < .05; Table 1). Post hoc analyses revealed a pattern of harmfulness ratings such that nonusers rated e-cigarettes as more harmful than single product and dual users. Similarly, hookah was rated as more harmful by nonusers compared to single, dual, and poly users. See Table 1.
Table 1.
Differences in ratings of absolute product harmfulness and health risks of smoking between tobacco use groups (N = 792).
| Items | Nonusers (N = 596) M (SD) |
Single Product (N = 113) M (SD) |
Dual Users (N = 49) M (SD) |
Poly Users (N = 34) M (SD) |
F | P |
|---|---|---|---|---|---|---|
| Absolute harmfulness | ||||||
| Cigarettes | 8.71 (2.20) | 8.50 (1.97) | 8.31 (1.97) | 8.62 (2.53) | 0.86 | 0.464 |
| SLT | 8.18 (2.47) | 7.91 (2.23) | 7.41 (2.24) | 6.94 (2.79) | 2.43 | 0.064 |
| Hookah | 6.37 (3.03)a | 5.25 (2.90)b | 4.88 (2.55)b | 5.73 (2.60) | 6.91 | < 0.001 |
| E-cigarettes | 6.15 (3.04)a | 5.16 (2.88)b | 4.34 (2.19)b | 4.24 (2.55)b | 7.78 | < 0.001 |
| Snus | 7.32 (2.77) | 6.64 (2.65) | 6.35 (2.61) | 6.67 (2.65) | 2.30 | 0.076 |
| Health risk of smoking | ||||||
| Lung Cancer - Smokers | 54.66 (26.43) | 48.65 (26.34) | 47.45 (26.74) | 48.50 (31.64) | 1.93 | 0.124 |
| Lung Cancer - NS | 25.78 (23.18) | 22.59 (19.92) | 17.73 (19.33) | 22.32 (21.49) | 1.26 | 0.287 |
| Heart Problems - Smokers | 55.39 (27.02) | 47.75 (25.51) | 49.71 (26.31) | 49.94 (31.58) | 2.51 | 0.058 |
| Heart Problems - NS | 35.94 (23.46) | 34.80 (22.75) | 30.57 (19.94) | 29.09 (18.82) | 0.83 | 0.478 |
Note. NS = Non-smoker; SLT = Smokeless tobacco. Significant pairwise comparisons are depicted by non-matching superscript letters. Harmfulness scale = 0 (not at all harmful) to 10 (extremely harmful). Health risk = 0 (no individuals) to 100 (100 individuals). Analyses controlled for gender, age, and ethnicity.
The number of products tried was associated with perceived absolute harmfulness above and beyond use status for all products. In each case, perceived harmfulness was significantly and negatively associated with the number of products tried. See Table 2 for a summary of regression results.
Table 2.
Hierarchical regression results predicting perceived product harmfulness and perceived risk (N = 792).
| Step 1, Demographics | Step 2, demographics + use status | Step 3, demographics + use status + number of products tried | |||||||
|---|---|---|---|---|---|---|---|---|---|
| R2 | F | β (95% CI) | R2 | F | β (95% CI) | R2 | F | β (95% CI) | |
| Perceived harmfulness | |||||||||
| Cigarettes | 0.02 | 3.29 | 0.02 | 0.81 | 0.06 | 29.69 | |||
| Gender | |||||||||
| Male | REF | - | - | ||||||
| Female | 0.11 (0.17 to 0.82)** | −0.09 (0.09 to 0.77) * | 0.05 (−0.11 to 0.57) | ||||||
| Age | −0.05 (−0.09 to 0.01) | −0.05 (−0.09 to 0.01) | −0.04 (−0.09 to 0.02) | ||||||
| Ethnicity | |||||||||
| White | REF | - | - | ||||||
| Black | 0.04 (−0.14 to 0.59) | 0.04 (−0.15 to 0.58) | 0.02 (−0.25 to 0.47) | ||||||
| Asian | −0.07 (−0.67 to 0.01) | −0.07 (−0.67 to 0.01) | −0.06 (−0.63 to 0.03) | ||||||
| Other | −0.01 (−0.12 to 0.09) | −0.01 (−0.12 to 0.08) | −0.02 (−0.12 to 0.08) | ||||||
| Use Status | |||||||||
| Nonuser | REF | - | - | ||||||
| Single product | −0.02 (−0.59 to 0.30) | 0.08 (−0.02 to 0.96) | |||||||
| Dual use | −0.02 (−0.82 to 0.48) | 0.08 (−0.01 to 1.41) | |||||||
| Poly use | −0.05 (−1.35 to 0.20) | 0.06 (−0.22 to 1.54) | |||||||
| # Products | −0.26 (−0.38 to −0.18)*** | ||||||||
| SLT | 0.02 | 3.08 | 0.03 | 2.31 | 0.06 | 24.40 | |||
| Gender | |||||||||
| Male | REF | - | - | ||||||
| Female | 0.12 (0.28 to 1.01)** | 0.10 (0.13 to 0.89)** | 0.06 (−0.08 to 0.69) | ||||||
| Age | −0.03 (−0.09 to 0.03) | −0.03 (−0.09 to 0.03) | −0.02 (−0.08 to 0.04) | ||||||
| Ethnicity | |||||||||
| White | REF | - | - | ||||||
| Black | 0.04 (−0.16 to 0.65) | 0.04 (−0.19 to 0.62) | 0.02 (−0.26 to 0.54) | ||||||
| Asian | −0.04 (−0.61 to 0.16) | −0.04 (−0.60 to 0.16) | −0.03 (−0.56 to 0.19) | ||||||
| Other | 0.01 (−0.10 to 0.13) | 0.01 (−0.10 to 0.13) | 0.01 (−0.10 to 0.13) | ||||||
| Use Status | |||||||||
| Nonuser | REF | - | - | ||||||
| Single product | −0.03 (−0.68 to 0.32) | 0.06 (−0.11 to 0.99) | |||||||
| Dual use | −0.05 (−1.27 to 0.19) | 0.03 (−0.46 to 1.13) | |||||||
| Poly use | −0.08 (−1.89 to −0.15)* | 0.02 (−0.76 to 1.22) | |||||||
| # Products | −0.24 (−0.40 to −0.17)*** | ||||||||
| E-cigarettes | 0.03 | 4.87 | 0.06 | 7.87 | 0.08 | 20.51 | |||
| Gender | |||||||||
| Male | REF | - | - | ||||||
| Female | 0.17 (0.63 to 1.52)*** | 0.12 (0.30 to 1.22)** | 0.08 (0.08 to 1.00)* | ||||||
| Age | −0.03 (−0.10 to 0.05) | −0.02 (−0.10 to 0.05) | −0.01 (−0.09 to 0.06) | ||||||
| Ethnicity | |||||||||
| White | REF | - | - | ||||||
| Black | −0.01 (−0.57 to 0.39) | −0.03 (−0.64 to 0.30) | −0.04 (−0.72 to 0.22) | ||||||
| Asian | 0.01 (−0.43 to 0.51) | 0.01 (−0.43 to 0.50) | 0.01 (−0.39 to 0.53) | ||||||
| Other | −0.04 (−0.22 to 0.06) | −0.04 (−0.22 to 0.06) | −0.04 (−0.22 to 0.05) | ||||||
| Use Status | |||||||||
| Nonuser | REF | - | - | ||||||
| Single product | −0.10 (−1.45 to −0.25)** | −0.02 (−0.84 to 0.49) | |||||||
| Dual use | −0.12 (−2.38 to −0.62)** | −0.04 (−1.49 to 0.45) | |||||||
| Poly use | −0.11 (−2.71 to −0.64)** | −0.02 (−1.45 to 0.93) | |||||||
| # Products | −0.22 (−0.45 to −0.18)*** | ||||||||
| Snus | 0.02 | 2.90 | 0.03 | 2.12 | 0.06 | 23.03 | |||
| Gender | |||||||||
| Male | REF | - | - | ||||||
| Female | 0.12 (0.27 to 1.10)** | 0.09 (0.12 to 0.98)* | 0.06 (−0.11 to 0.76) | ||||||
| Age | −0.01 (−0.08 to 0.06) | −0.01 (−0.07 to 0.06) | 0.00 (−0.07 to 0.07) | ||||||
| Ethnicity | |||||||||
| White | REF | - | - | ||||||
| Black | 0.07 (−0.01 to 0.90) | 0.06 (−0.04 to 0.87) | 0.05 (−0.13 to 0.77) | ||||||
| Asian | 0.01 (−0.36 to 0.50) | 0.01 (−0.37 to 0.49) | 0.02 (−0.33 to 0.52) | ||||||
| Other | −0.02 (−0.16 to 0.10) | −0.02 (−0.16 to 0.10) | −0.02 (−0.16 to 0.10) | ||||||
| Use Status | |||||||||
| Nonuser | REF | - | - | ||||||
| Single product | −0.07 (−1.14 to −0.00) | 0.01 (−0.53 to 0.72) | |||||||
| Dual use | −0.06 (−1.54 to 0.09) | 0.02 (−0.66 to 1.13) | |||||||
| Poly use | −0.03 (−1.41 to 0.55) | 0.07 (−0.18 to 2.05) | |||||||
| # Products | −0.23 (−0.44 to −0.19)*** | ||||||||
| Hookah | 0.01 | 0.82 | 0.03 | 6.95 | 0.05 | 14.65 | |||
| Gender | |||||||||
| Male | REF | - | - | ||||||
| Female | 0.05 (−0.11 to 0.80) | 0.01 (−0.39 to 0.55) | −0.02 (−0.59 to 0.36) | ||||||
| Age | 0.01 (−0.06 to 0.09) | 0.02 (−0.05 to 0.09) | 0.03 (−0.05 to 0.10) | ||||||
| Ethnicity | |||||||||
| White | REF | - | - | ||||||
| Black | −0.02 (−0.63 to 0.37) | −0.03 (−0.69 to 0.30) | −0.04 (−0.77 to 0.22) | ||||||
| Asian | 0.04 (−0.23 to 0.72) | 0.03 (−0.24 to 0.69) | 0.04 (−0.21 to 0.72) | ||||||
| Other | −0.02 (−0.17 to 0.11) | −0.01 (−0.17 to 0.11) | −0.01 (−0.17 to 0.11) | ||||||
| Use Status | |||||||||
| Nonuser | REF | - | - | ||||||
| Single product | −0.13 (−1.72 to −0.49)*** | −0.06 (−1.20 to 0.16) | |||||||
| Dual use | −0.12 (−2.38 to −0.60)** | −0.05 (−1.63 to 0.33) | |||||||
| Poly use | −0.04 (−1.69 to 0.44) | 0.04 (−0.66 to 1.78) | |||||||
| # Products | −0.19 (−0.41 to −0.13)*** | ||||||||
| Perceived risk | |||||||||
| Smokers - Lung Cancer | 0.01 | 1.97 | 0.02 | 1.97 | 0.03 | 5.61 | |||
| Gender | |||||||||
| Male | REF | - | - | ||||||
| Female | 0.07 (0.12 to 8.12)* | 0.05 (−1.37 to 6.95) | 0.03 (−2.50 to 5.98) | ||||||
| Age | 0.07 (−1.27 to 0.04) | −0.63 (−1.25 to 0.06) | −0.06 (−1.20 to 0.11) | ||||||
| Ethnicity | |||||||||
| White | REF | - | - | ||||||
| Black | 0.47 (−5.87 to 2.69) | −0.03 (−6.23 to 2.34) | −0.04 (−6.63 to 1.94) | ||||||
| Asian | 0.36 (−2.24 to 6.12) | 0.03 (−2.35 to 6.02) | 0.03 (−2.18 to 6.17) | ||||||
| Other | 0.43 (−1.75 to 0.74) | −0.03 (−1.77 to 0.72) | −0.84 (−1.77 to 0.71) | ||||||
| Use Status | |||||||||
| Nonuser | REF | - | - | ||||||
| Single product | −0.07 (−10.73 to 0.14) | −0.03 (−8.10 to 4.00) | |||||||
| Dual use | −0.05 (−13.96 to 1.98) | −0.01 (10.17 to 7.50) | |||||||
| Poly use | −0.04 (−15.02 to 3.76) | 0.01 (−9.78 to 12.05) | |||||||
| # Products | −0.12 (−2.76 to −0.26)* | ||||||||
| Smokers - Heart Problems | 0.01 | 1.34 | 0.02 | 2.51 | 0.03 | 9.03 | |||
| Gender | |||||||||
| Male | REF | - | - | ||||||
| Female | 0.07 (−0.21 to 7.91) | 0.04 (−1.66 to 6.77) | 0.02 (−3.07 to 5.50) | ||||||
| Age | −0.02 (−0.89 to 0.44) | −0.02 (−0.86 to 0.47) | −0.01 (−0.79 to 0.53) | ||||||
| Ethnicity | |||||||||
| White | REF | - | - | ||||||
| Black | −0.03 (−6.19 to 2.49) | −0.04 (−6.56 to 2.12) | −0.04 (−7.07 to 1.59) | ||||||
| Asian | 0.03 (−2.38 to 6.10) | 0.03 (−2.61 to 5.87) | 0.03 (−2.38 to 6.06) | ||||||
| Other | −0.04 (−1.93 to 0.59) | −0.04 (−1.97 to 0.56) | −0.04 (−1.97 to 0.54) | ||||||
| Use Status | |||||||||
| Nonuser | REF | - | - | ||||||
| Single product | −0.09 (−12.63 to −1.62)* | −0.04 (−9.08 to 3.15) | |||||||
| Dual use | −0.04 (−12.70 to 3.44) | 0.01 (−7.59 to 10.27) | |||||||
| Poly use | −0.04 (−14.49 to 4.54) | 0.03 (−7.33 to 14.73) | |||||||
| # Products | −0.15 (−3.20 to −0.67)** | ||||||||
| Nonsmokers - Lung Cancer | 0.02 | 2.62 | 0.02 | 1.34 | 0.02 | 0.22 | |||
| Gender | |||||||||
| Male | REF | - | - | ||||||
| Female | 0.12 (2.27 to 9.00)** | 0.10 (1.23 to 8.22)** | 0.09 (0.98 to 8.13)* | ||||||
| Age | 0.02 (−0.39 to 0.71) | 0.02 (−0.38 to 0.72) | 0.02 (−0.37 to 0.73) | ||||||
| Ethnicity | |||||||||
| White | REF | - | - | ||||||
| Black | −0.03 (−5.14 to 2.05) | −0.03 (−5.37 to 1.83) | −0.04 (−5.45 to 1.78) | ||||||
| Asian | 0.01 (−3.14 to 3.89) | 0.01 (−3.13 to 3.91) | 0.01 (−3.10 to 3.94) | ||||||
| Other | −0.04 (−1.66 to 0.43) | −0.04 (−1.64 to 0.46) | −0.04 (−1.64 to 0.46) | ||||||
| Use Status | |||||||||
| Nonuser | REF | - | - | ||||||
| Single product | −0.04 (−7.04 to 2.10) | −0.03 (−7.03 to 3.17) | |||||||
| Dual use | −0.07 (−12.89 to −0.51) | −0.06 (−12.86 to 2.04) | |||||||
| Poly use | −0.02 (−9.81 to 5.98) | −0.01 (−9.98 to 8.42) | |||||||
| # Products | −0.02 (−1.31 to 0.80) | ||||||||
| Nonsmokers - Heart Problems | 0.02 | 2.77 | 0.02 | 0.91 | 0.02 | 1.04 | |||
| Gender | |||||||||
| Male | REF | - | - | ||||||
| Female | 0.10 (1.68 to 8.55)** | 0.09 (0.76 to 7.92)* | 0.08 (0.30 to 7.60)* | ||||||
| Age | 0.03 (−0.31 to 0.82) | 0.03 (−0.31 to 0.82) | 0.03 (−0.29 to 0.84) | ||||||
| Ethnicity | |||||||||
| White | REF | - | - | ||||||
| Black | −0.06 (−6.99 to 0.35) | −0.07 (−7.18 to 0.18) | −0.07 (−7.34 to 0.05) | ||||||
| Asian | −0.01 (−4.16 to 3.01) | −0.01 (−4.10 to 3.09) | −0.01 (−4.04 to 3.15) | ||||||
| Other | −0.05 (−1.80 to 0.34) | −0.05 (−1.82 to 0.32) | −0.05 (−1.82 to 0.32) | ||||||
| Use Status | |||||||||
| Nonuser | REF | - | - | ||||||
| Single product | −0.01 (−5.35 to 4.00) | 0.01 (−4.69 to 5.74) | |||||||
| Dual use | −0.04 (−10.58 to 3.12) | −0.02 (−9.92 to 5.61) | |||||||
| Poly use | −0.05 (13.66 to 2.48) | −0.03 (−12.49 to 6.32) | |||||||
| # Products | −0.05 (−1.64 to 0.52) | ||||||||
Note. SLT = smokeless tobacco;
p < .000,
p < .01,
p < .05.
3.3. Perceived health risks of being a smoker
Tobacco use groups did not differ significantly in reports of how many smokers would develop lung cancer and heart disease. See Table 1.
The number of products tried was associated with perceived health risk above and beyond use status for the number of smokers participants believed would die of lung cancer and heart problems but not for the number of nonsmokers that would die of these problems. In each case, perceived health risk was significantly and negatively associated with the number of products tried. See Table 2 for a summary of regression results.
4. Discussion
The present study demonstrates that the number of tobacco products tried is significantly and negatively associated with perceived harmfulness above and beyond use status across all tobacco products assessed. Consistent with previous research (Choi & Forster, 2014; Villanti et al., 2015; Wackowski & Delnevo, 2016), nonusers reported the highest ratings of perceived harmfulness. These findings are consistent with theories such as the theory of planned behavior and the health belief model which assert that increased perceived risk is associated with decreased engagement in the target behavior (Glanz, Rimer, & Viswanath, 2008). In the current sample, dual and polytobacco use were associated with lower perceived risk, potentially indicating habituation to the harmfulness of tobacco products with increased exposure. While the cross-sectional nature of the data precludes determination of temporality, these findings also warrant further examination of the acquired capability for tobacco use model (Meier et al., 2015), which proposes that use of tobacco products leads to habituation of the associated harmfulness and makes use of other products easier. However, additional research is needed to establish temporality of these effects.
Given the emerging trend of polytobacco use (Fix et al., 2014; Kasza et al., 2017), the relationship between experimentation and perception of harm is particularly important for prevention efforts. Even minimal experimentation with tobacco in adolescence is associated with later daily cigarette (Sargent, Gabrielli, Budney, Soneji, & Wills, 2017) and polytobacco use (Meier et al., 2015). Intervention and prevention practices may be improved by balancing the nuances of different tobacco products’ health risk with the message that there are no safe tobacco products. Some concern is warranted given that consumers often perceive cigarettes as the most harmful product and all others as comparatively much less harmful (Ambrose et al., 2014; Smith, Curbow, & Stillman, 2007). Evidence suggests adults are able to understand and integrate nuanced information regarding the continuum of risk and harms associated with different tobacco products (Biener, Nyman, Stepanov, & Hatsukami, 2014; Borgida et al., 2015). Therefore, future research should test the impacts of providing education to youth regarding the relative risks associated with different tobacco products. In addition to providing more nuanced information regarding the continuum of risk, intervention efforts should specifically assess and target habituation to risk as tobacco use progresses. Education focused on correcting misperceptions of risk may be efficacious but necessitate empirical testing.
The current study is not without limitations. The study utilized cross-sectional data, rendering temporal conclusions impossible; it may be that perceptions of harm influence choice of tobacco product usage versus product usage impacting harm perception. Prospective studies are needed to understand the temporal associations of product use, particularly polytobacco use, and perceptions of harm. Further, results may not be generalizable to a more diverse sample given that the current sample was composed of undergraduate students from a Midwestern university who self-selected into the current study. It is possible that with a more representative sample, a different pattern of results may emerge. Future research should replicate the current research among more diverse and representative samples. The current study did not assess extensive sample characteristics. Future research should include more comprehensive demographic information such as student major. The current study only examined two negative health outcomes (lung cancer and heart problems). A significant portion of the adolescent and young adult literature focuses on perceptions of harm and outcome expectancies associated with nicotine/tobacco use (e.g., stress relief, increased concentration; Creamer, Delk, Case, Perry, & Harrell, 2017) rather than linking use to specific acute health effects. Future research should examine a greater range of health outcomes, particularly those that are more proximal and salient to young adults. Relatedly, health outcomes were only assessed in relation to cigarette smoking, therefore future research should examine health outcomes as they relate to tobacco use more generally. Finally, future research should utilize more comprehensive measures of harm perceptions including individual’s use (e.g., continued use over the next year), a specific time period (e.g., harm to health in the next 10 years), and a consistent target (e.g., harm to a third person smoker/nonsmoker; Brewer, Weinstein, Cuite, & Herrington, 2004).
The present investigation begins to answer questions regarding how perceptions of harm and health risk of nicotine-containing products vary by tobacco/nicotine product use and how these perceptions are related to actual use of products. Given that number of unique products used was associated with reduced risk perception, it suggests that interventions correcting such perceptions in order to curb further use may be important for reducing the uptake of newer tobacco or nicotine-containing products. Further research examining the temporal associations between product use and risk perceptions is warranted to better understand the sequencing of these relationships.
HIGHLIGHTS.
Nonusers rated e-cigarettes and hookah as more harmful than all other groups.
Trying a greater number of products was associated with lower perceived harmfulness.
Number of products tried was a unique predictor of perceived harmfulness.
Number of products tried was a unique predictor of perceived health risk.
Prevention and interventions may be needed to address habituation to risk.
Funding
ELSL is supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number F31 DA04252. ACV was supported by the Tobacco Centers of Regulatory Science (TCORS) award P50DA036114 from the National Institute on Drug Abuse and Food and Drug Administration (FDA) and the Centers of Biomedical Research Excellence P20GM103644 award from the National Institute on General Medical Sciences. TLW is supported by funds from the Oklahoma Tobacco Settlement Endowment Trust, and by R03DA041928 from the FDA and NIDA and R01CA204891 from the NCI. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Food and Drug Administration.
Footnotes
Declarations of interest
None.
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