Communicating the Relative Health Risks of E-Cigarettes: An online experimental study exploring the Effects of a Comparative Health Message versus the EU Nicotine Addiction Warnings on Smokers’ and Non-Smokers’ Risk Perceptions and Behavioural Intentions

Abstract Introduction This study investigated the effects of the European Union Tobacco Products Directive [EU-TPD] Article 20 E-cigarette (EC) health warnings (“This product contains nicotine which is a highly addictive substance. [It is not recommended for non-smokers.]”) and a comparative harm message (“Use of this product is much less harmful than smoking” [COMP]) on smokers’ and non-smokers’ perceptions and behavioural intentions. Methods 2495 UK residents (1283 smokers and 1212 non-smokers) self-reported perceived harm, addictiveness, EC effectiveness, social acceptability, and intentions to purchase and use EC, and in smokers, intentions to quit and intentions to use EC in future quit attempts. These were measured before and after exposure to EC images containing either the TPD, COMP, TPD+COMP or no message. Results Non-smokers had higher harm, addictiveness and lower social acceptability perceptions compared to smokers. TPD presence increased, whilst COMP decreased, harm and addictiveness perceptions in both groups. There were no effects on social acceptability, EC effectiveness or intentions to use. In smokers only, intentions to purchase an EC were higher following exposure to the COMP alone vs. TPD alone. TPD presence also significantly reduced smokers’ quit intentions compared to COMP alone. Conclusion Current EU nicotine warnings may have the unintended consequence of increasing smokers’ harm and addictiveness perceptions related to EC, deter purchase intentions and decrease quit intentions. These effects can possibly be reversed with a comparative message which de-emphasises EC harms in the context of smoking. These results can further our understanding of how to communicate EC relative health risk information.