Comparative risk perceptions of switching to JUUL vs. continued smoking and subsequent switching away from cigarettes: a longitudinal observational study

Abstract

Background: Evidence indicates that electronic nicotine delivery systems (ENDS) pose lower risk than cigarettes; however, many smokers harbor misperceptions that ENDS are equally or more harmful, possibly deterring them from switching. This study examines whether comparative risk perceptions of JUUL vs. smoking are associated with subsequent switching, among smokers who recently purchased JUUL.

Methods: N = 16,996 current established smokers who recently purchased a JUUL Starter Kit were followed 6 times over 12 months. Comparative risk perceptions were assessed using both direct and indirect measures (i.e., contrasting JUUL and smoking directly in questions, and deriving from separate absolute scales). Repeated-measures logistic regression examined switching across follow-up (no smoking in past 30 days) as a function of baseline risk perceptions, adjusting for demographics and baseline smoking behavior.

Results: Perceiving JUUL as less harmful than smoking was associated with higher switching rates, using both direct (e.g., adjusted odds ratio [AOR] = 1.48 for "JUUL much less" vs. "more/much more harmful") and indirect (AOR = 1.07, for each 10-unit increase in fraction; AOR = 1.51 for highest (6-100) vs. lowest (0 to < 1) fraction categories) comparative risk measures (all p < 0.0001). Among the subset smoking 10 + cigarettes per day, associations between risk perceptions and switching were more pronounced (AOR = 2.51 for "JUUL much less" vs. "more/much more harmful"; AOR = 1.81 for 6-100 vs. 0 to < 1 fraction, both p < 0.0001).

Conclusions: Smokers who perceive JUUL as less harmful than cigarettes have higher odds of switching. Future research should examine whether messaging which aligns comparative risk perceptions with current evidence can facilitate switching, especially among heavier smokers.

Keywords: Cigarettes; Electronic nicotine Delivery Systems; JUUL; Risk perceptions; Smoking; Switching.

Fig. 1

AORs and switching rates by comparative risk perception groups, among all baseline established smokers. A and B: Adjusted odds ratios (AORs) for switching (y-axis) for risk perception groups (x-axis), for both direct (A) and indirect (B) comparative risk perceptions. C and D: Average adjusted switching rates across direct (C) and indirect (D) risk perception groups. Analyses adjust for baseline smoking history and demographic characteristic (see text for details) (see text for details). Brackets and * indicate significance at p<.05 between adjacent categories based on GEE model (see text). Indirect comparative risk fraction = 1 indicates equal perceived risk of switching to JUUL and continued smoking, and is included in the “=1 to <2” group. Indirect risk fraction <1 (“=0 to <1” group) indicates that continued smoking is perceived to be less risky than switching to JUUL; values > 1 indicate that switching to JUUL is perceived to be less risky than continued smoking

Fig. 2

AORs and switching rates by comparative risk perception groups, among baseline established smokers with 10+CPD. A and B: Adjusted odds ratios (AORs) for switching (y-axis) for risk perception groups (x-axis), for both direct (A) and indirect (B) comparative risk perceptions. C and D: Average adjusted switching rates across direct (C) and indirect (D) risk perception groups. Analyses adjust for baseline smoking history and demographic characteristic (see text for details) (see text for details). Brackets and * indicate significance at p<.05 between adjacent categories based on GEE model (see text). Indirect comparative risk fraction = 1 indicates equal perceived risk of switching to JUUL and continued smoking, and is included in the “=1 to <2” group. Indirect risk fraction <1 (“=0 to <1” group) indicates that continued smoking is perceived to be less risky than switching to JUUL; values > 1 indicate that switching to JUUL is perceived to be less risky than continued smoking