Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries Open Access

Nicotine is best known as a constituent of tobacco and for its use as a tobacco cessation aid (National Center for Biotechnology Information, 2004). Burning tobacco releases thousands of substances, many of which can increase a user’s risk for disease including cancer, respiratory disease and cardiovascular diseases (Reitsma et al., 2017). Research on nicotine specifically is more limited; while the majority of work has been on potential harmful effects some researchers believe that exploring therapeutic applications involving nicotine could lead to new discoveries (Bertrand and Terry, 2018). Studies that focused on potential negative consequences of nicotine reported on brain development in adolescents and on the developing fetus of pregnant women consuming nicotine in any form Sailer et al. (2019), Yuan et al. (2015). In terms of therapeutic applications, extensive research on nicotine to treat Parkinson’s or Alzheimer’s diseases consistently showed promising initial results, but so far most leads faltered during the clinical trial phase (Newhouse, 2019).

There has been a recent increase in nicotine research coinciding with the increased availability of alternate methods of nicotine delivery via ecigarettes and other tobacco harm reduction (THR) products. Many users of THR products are smokers who are trying to quit, but there has also been a marked uptake by adolescents, renewing concerns over nicotine’s potential adverse effects (National Academy of Sciences Engeneering and Medicine, 2018). Article 14 from the framework convention on tobacco control (FCTC) calls upon members to promote tobacco cessation and to support tobacco users in quitting by implementing effective measures (World Health Organization, 2003). An ongoing emotional debate surrounding THR products has so far kept many governments from promoting THR products to lessen the burden of disease caused by tobacco. Article 12 from the FCTC requires parties to raise public awareness on health risks of tobacco through all available media channels. A reason why users of tobacco and THR products around the world find it hard to distinguish between the health risks of smoking and nicotine use may be due to conflicting messages from the media that deviate from the most recent scientific evidence base, overemphasize certain opinions or omit findings that do not align with their readers’ beliefs. In light of the debate around THR products, it is vital for the public to be aware of what exactly nicotine is and how it can affect a person’s behavior and health via consumption. A study published by the Royal Society for Public Health in 2015 reported that more than three quarters of smokers and non-smokers in the United Kingdom (UK) believe nicotine is harmful to health (Royal Society for Public Health, 2015). A study in the United States (US) reported that about half of all men and women believed that nicotine causes cancer, with a quarter of the population being unsure (O’Brien et al., 2017). Most studies on risk perceptions involving nicotine focus on THR products, very low nicotine content cigarettes or nicotine replacement therapies (NRTs), not on the substance itself. A poll in 13 countries commissioned by the Foundation for a Smoke-Free World in 2017 reported that in many countries a vast majority of consumers tend to use the terms “nicotine” and “cigarettes” interchangeably, thereby suggesting a lack of awareness that nicotine consumption via THR products may not carry the same health risks as when smoking combustible tobacco (Riahi et al., 2019).

We conducted a survey with current and former users of tobacco and THR products in seven countries and asked them about usage patterns and risk perceptions of nicotine. To put results into context, we also examined the media dialogue leading up to the poll in four of these countries to estimate the extent to which public opinion may have been influenced by media messaging.

The survey was conducted in seven countries, namely, Greece (GR), India (IN), Japan (JP), Norway (NO), South Africa (SA), the UK and the US between June and September 2019 by Nielsen, a global measurement and data analytics company. Nielsen was chosen as a partner from a pool of applicants following a competitive request for proposals. The margins of error for the sample sizes at a 95% confidence interval ranged from 0.5% (IN) to 2.6% (GR and NO). The survey captured participants’ demographic data, their habits and perceptions regarding tobacco and THR products and their experiences around quitting tobacco products. Adults between 18–69 years of age (20–69 for JP) who were current users of any tobacco or THR product and quitters who quit within the past five years were eligible to participate. The survey was administered online in NO, JP, UK and the US, countries with more uniform internet penetration. Face-to-face computer-aided interviews were performed in IN, GR and SA using a stratified random sampling method. Full details on the sampling methodology have been published elsewhere (Foundation for a Smoke-Free World, 2019).

Internal Review Board (IRB) exemption in the US was obtained from solutions IRB (protocol 2019/06/4 foundation for a smoke-free world global poll 2019) according to 45CFR46.101 (b) as this research was not of a clinical nature and no identifiable data was collected. Authorities in the remaining countries confirmed that for anonymous surveys no ethics approval was required.

Nielsen conducted a total of 69 pilot interviews for cognitive testing of the survey, ensuring that participants understood the survey and translations of the questions. Further details on the pilot interviews can be found in the Appendix (Table A4). A large portion of the survey was extracted from pretested social surveys (Hamilton et al., 2011; International Tobacco Control Policy Evaluation Project, 2020). Language-specific changes were implemented following the pilot phase.

Response rates for the online surveys were calculated by dividing the number of complete interviews by the number of times the survey link had been opened and the questionnaire started. Other participants were either screened out or left the questionnaire incomplete. Response rates for the face-to-face interviews were not recorded.

To assess risk perceptions of nicotine, we asked survey participants if they believed nicotine is harmful, if they thought that tobacco-related cancer is primarily caused by nicotine and if they thought that NRTs and nicotine in e-cigarettes cause cancer. Subjects estimated the harmfulness of several consumer products, namely, cigarettes, coffee, tea, soda drinks, wine/beer/spirits and candy on a scale from 1 (not at all harmful) to 10 (very harmful). In addition, we asked them to rate some substances that are commonly known ingredients of these products, namely, salt, sugar, caffeine, nicotine, fat and alcohol.

Select responses to the survey questions were merged into fewer categories to simplify analyzes. Participants not identifying with either sex were excluded from the present analysis due to the inadequate sample size. Participants were grouped into low (no degree at all including those who completed some high school), middle (a high school degree, job-specific training after high school or some college education but no college degree) and high (at least a college degree) education levels. Nielsen income brackets were used to group participants into low, middle or high socioeconomic status (SES) as seen in Appendix Table A1. Employment response options were dichotomized into “employed” (including housekeepers and students) or “unemployed” (including temporarily laid-off individuals, permanently or temporarily disabled or sick people, women on maternity leave and retired individuals) groups. Relationship status was also dichotomized into “single” (including separated, divorced or widowed) or “in a relationship” groups. Participants were also categorized as either living in a household with at least one child below 14 years of age or not.

Participants were categorized into user groups based on the types of tobacco or THR products they use and the frequency with which they use them. We created six user groups for both current users and quitters. Exclusive daily combustible users used only combustible products and at least one of those products on a daily basis. Combustible products include factory-made cigarettes, tubed cigarettes, rolled cigarettes, capsule/flavored cigarettes, cigars and cigarillos, water pipes, hookahs, shishas, pipes and bidis. For IN, this group was further divided into daily users of bidis only and daily users of the remaining combustible products with at least one used daily. Exclusive daily non-combustible users used only vaping products (with or without nicotine) or heat-not-burn tobacco products with at least one used daily. Exclusive daily smokeless users used only smokeless tobacco products, which included moist smokeless tobacco, loose leaf chewing tobacco, dry snuff, snus, dissolvable tobacco products, gutka and other chewing tobacco. Daily dual/poly users used any number and combination of the aforementioned products, as well as NRT products with at least one product used daily. Non-daily users used any number and combination of the previously mentioned products, but none on a daily basis. Non-users are individuals who did not qualify for any of the previous groups (i.e. they used any product type or combination of products less than monthly or were unsure of how frequently they used it).

Data were analyzed using stata/SE 15.1 (statacorp LP, college station, TX) and R version 3.6.1 (R foundation for statistical computing, Vienna, Austria). All data collected were summarized using descriptive statistics. Participants who preferred not to answer a question or responded with “I do not know” were excluded from that particular statistic unless otherwise mentioned.

To obtain earned coverage, i.e. free media coverage, pertaining to mentions of “nicotine,” a master search query was set up for English language publications in IN, SA, the UK and the US. The goal of each country-specific search query was to perform data collection across the various top tier media outlets (publications with at least one million unique monthly visitors). Only releases between May 1 and July 31, 2019 were included. Given the common use of the word “nicotine,” exclusions were set up by filtering out any mentions of “nicotine” in press releases, earnings and stock news and market research reports. Quantitative and qualitative analyzes were conducted upon data collection to determine the share of voice (SoV) by measuring the volume of mentions for each country, social amplifications (top shared articles in each country), types of mentions of “nicotine” (e.g. headline mentions v/s mentions in the body) and perception of nicotine and themes pertaining to it. The SoV for each country was calculated by dividing the country-specific outcome by the sum of all analyzed countries.

We surveyed a total population of 54,279 participants, 11,350 women, 42,917 men and 12 persons not identifying with either sex. There were 46,220 current users and 8,047 participants who had quit using any tobacco or THR product within the past five years. Response rates in the online surveys were 8.7% for JP, 25.8% for NO, 9.0% for the UK and 23.5% for the US. In all countries except the UK our sample of men was larger than that of women. The mean age ranged from 36.7 [Standard Deviation (SD), 15.1; NO]to 45.2 years (SD, 12.6; JP) in women and from 35.2 (SD, 12.7; IN) to 50.7 years (SD, 11.7; JP) in men (Table 1). SES distribution was fairly even between low, middle and high classes in the UK and US, while in the other surveyed countries, the high SES class was less represented by our sample.

In all countries, a large fraction of current users were exclusive daily combustible tobacco users (Table 2). IN had a large group of exclusive smokeless tobacco users, especially among women (58.5%), with NO being the only other country with the proportion of exclusive smokeless tobacco users above 10%. (11.0% women and 10.5% men). Dual and poly users who used at least one product on a daily basis were widespread in all countries except in GR and SA, especially US women more often tended to use several product types daily. Among quitters, the distribution of groups was similar with a few exceptions.

Beliefs on the harmfulness of nicotine were similar among women and men in all countries. The majority of respondents in all countries stated that nicotine is harmful; this number was lowest in IN [69.9% women, 68.3% men (Figure 1)]. Between 43.7% (UK men) and 78.0% (SA men) incorrectly agreed that nicotine is the primary cause of cancer from tobacco (Figure 2). Around half the US and Indian study population of current users believed that NRTs cause cancer while in other countries this fraction was smaller (Figure 3). Between 55.7% (UK) and 91.5% (IN) of those who thought nicotine was harmful also stated that it is the primary cause of tobacco-related cancer (Appendix Table A5). Among the group stating that nicotine is the primary cause of tobacco-related cancer, between 42% (UK) and 75.5% (IN) believed that nicotine in NRTs or e-cigarettes causes cancer (Appendix Table A5). Among quitters, similarly, the majority in all countries believed that nicotine is harmful. The proportion of quitters who believed that nicotine is the primary cause of cancer was slightly higher than among current users in all countries.

When stratifying the above estimates by user groups, several subgroups in many countries were too small to analyze meaningfully, especially among former users. There were few clear trends visible between the groups.

When estimating the harmfulness of a range of consumer products and the substances contained therein, all current user groups rated cigarettes the most harmful [7.4 (SD 1.9) in Norwegian men to 8.9 (SD 1.7) in UK women (Figure 4)]. In NO and IN, alcohol and wine/beer/spirits, in GR and JP, nicotine and fat and in SA, the UK and the US, nicotine and alcohol were generally rated higher on the products and substances harmfulness scales. JP had the lowest overall ratings for products and substances among current users. The top three rated products and substances were the same for current users and quitters.

The US led the coverage on nicotine in top tier media outlets with 1,992 mentions and 77% SoV while the UK (327 mentions; 13% SoV) and IN (244 mentions; 10% SoV) were a distant second and third, respectively. Of the total 2,573 top tier media articles that mentioned nicotine, only around 5% had “nicotine” in their headline. The tonality of the coverage pertaining to nicotine skewed largely negative with almost 30% of all mentions including a reference to the addictive nature of the substance and the dangers of dependency. The world no tobacco day on May 31 saw a spike in mentions of nicotine in IN though not specific to a particular type of tobacco. Firstpost, an Indian news and media website, ran a story on May 31, that advocated for the increase in the use of e-cigarettes as a means for getting over tobacco addiction (The smoker’s guide to why vaping is the first step in the road to quitting cigarettes, 2019), but on the same day the Times of IN reported that the state of Maharashtra was banning e-cigarettes claiming they were as harmful as tobacco products (Maharashtra bans ecigarette, says use as harmful as tobacco, 2019). In the US and the UK, the San Francisco e-cigarette ban story in June caused a major spike in mentions related to nicotine and nicotine addiction and was covered in outlets from the other countries as well. While there was some debate about the efficacy of ecigarettes in serving as a cessation tool, there was no coverage pointing to the therapeutic uses of nicotine.

Media coverage on nicotine leading up to our poll was predominantly negative. Most survey participants believed that nicotine is harmful and assumed that both cigarettes and nicotine are similar in terms of the level of harmfulness.

When examining the media dialogue leading up to the poll, we found that selective coverage was used, sometimes in addition to spreading misleading stories and omitting stories that potentially contradicted a desired message. The conveyed messages seemed to both confirm and strengthen widespread negative beliefs about nicotine. Therapeutic effects and potential beneficial applications of nicotine were completely ignored by the media leading up to the poll despite ongoing research in this field.

Nicotine was considered harmful across all subgroups surveyed in our poll and a large part of current and former users believed it is the primary cause of tobacco-related cancer. These findings are in line with previous studies. A British report from 2015 stated that 78% of smokers believed that nicotine is harmful to health (Royal Society for Public Health, 2015), very similar to the 81.4% and 79.3% we found among smoking women and men, respectively, in the UK (Appendix Table A2). Not much has changed in recent years in terms of nicotine perception despite the ongoing discussion in the media. A more recent study from the UK reported that only 9.8% of female and 12.3% of male current and former smokers thought that none or just a small amount of health harms of tobacco cigarettes comes from nicotine (Wilson et al., 2019). In the same study 59.1% of women and 62.1% of men said that nicotine in cigarettes is not what causes most of the cancer. Again, these numbers come close to what we observed in our UK sample with 44.6% of women and 43.7% of men incorrectly saying that nicotine is the primary cause of tobacco-related cancer (Figure 2). In a US study, half the population incorrectly agreed that nicotine is the substance that causes most of the smoking-related cancers while a quarter was unsure (O’Brien et al., 2017); in our US sample, it was 58.9% for women and 55.2% for men (Figure 2). Studies on nicotine perceptions from the other five countries are lacking. We found that in most countries a large part of the population who believed that nicotine is harmful did not believe that it was the primary cause of tobacco-related cancer indicating that the perceived harmfulness may be related to other diseases. Even if participants believed it was the primary cause of tobacco-related cancer they often disagreed when asked if the nicotine in e-cigarettes or NRTs cause cancer. This underlines the confusion regarding nicotine and suggests that nicotine is assessed differently depending on the product it is linked to. Comparability with studies that evaluated specific products instead of nicotine itself is limited, although these are becoming more common.

We observed that the majority of current and previous product users estimated the harmfulness of nicotine and cigarettes alike. This has led to the misled conclusion that nicotine is responsible for the detrimental effects related to combustible tobacco consumption, even though science has found only very limited and often inconclusive evidence to date that nicotine is any more harmful than other legally consumed stimulants. The belief that nicotine is the primary culprit of smoking-related harm to health seems to be deeply engrained in many people’s minds as the substance and the product are often not separated in commonplace conversations. This may continue to skew perception and further the idea that nicotine and the specific tobacco product are equal. Contradictory statements by leading researchers supported by renowned funding agencies and misreporting by the media may further public confusion as people have stated they use the media as a source of health information (Gartner et al., 2020). The media could play a decisive role in raising awareness that nicotine is delivered through various products that represent a continuum of risk. Tobacco cessation through THR product use requires a more pragmatic and balanced approach in communications. It remains uncertain how much of the confusion surrounding nicotine can be blamed on inaccurate media messages but this phenomenon has been observed with other topics as well (Wilson et al., 2009; Maggio et al., 2019; Moghimi and Wiktorowicz, 2019). Journalists may be pressed for time to produce a catchy headline or ill-qualified to interpret statistical outcomes and assess expert opinions. Research has shown that stories written by specialist health journalists working for a single media outlet are of higher quality than other categories of journalists (Wilson et al., 2010). Standardized evidence scales for lay audiences have been among the solutions proposed but these may prove challenging to enforce (Braithwaite, 2011). Accurate, timely and complete reporting by the media is necessary to avoid further public misunderstanding and mistrust (Gartner et al., 2020).

The survey was conducted simultaneously in all countries minimizing the influence from the fast-paced media dialogue that may have changed the populations’ beliefs. The following limitations are to be noted: Using online surveys in some countries and face-to-face interviews in others may have introduced a selection bias among the population, especially in terms of SES and education. Response rates were not recorded for the face-to-face interviews. The questions we asked about nicotine were newly formulated and had not been validated in previous studies. We could not discuss the effects for GR, NO and JP as the media dialogue assessment was limited to english language publications in (partly) english-speaking countries. Given the timing of these analyzes, there is further need to evaluate how recent media events may have altered public perception.

In alignment with the recommendations found in articles 12 and 14 of the FCTC, the media should take responsibility for an unbiased and truthful communication of the latest state of knowledge regarding health risks of both tobacco and THR products and tobacco cessation treatment strategies should be based on the best available evidence of effectiveness. It is important to clarify differences between nicotine and various products as perceived relative harm may influence future product switching (Persoskie et al., 2019), which, in turn, could impact cessation rates and public health.

Competing Interests: The authors declare no competing interests. Funding: This survey was fully funded by the Foundation for a Smoke-Free World and no grants or other financial sources were involved.

Expression of concern: The publisher of the journal Drugs and Alcohol Today is issuing an Expression of concern for the following article Rajkumar, S., Adibah, N., Paskow, M.J. and Erkkila, B.E. (2020), “Perceptions of nicotine in current and former users of tobacco and tobacco harm reduction products from seven countries”, published in Drugs and Alcohol Today, Vol. 20 No. 3, pp. 191-206, to inform readers that credible concerns have been raised regarding the editorial process for this article. An investigation is ongoing and is currently unresolved. Further information will be provided by Drugs and Alcohol Today as it becomes available.

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Table A5