Relative Risk Perceptions of Switching to JUUL vs. Continued Smoking and Subsequent Switching away from Cigarettes: A Longitudinal Observational Study

Abstract

Abstract Background: Evidence indicates that electronic nicotine delivery systems (ENDS) pose lower risk than cigarettes; however, many smokers misperceive ENDS to be equally ormore harmful, possibly deterring them from switching. This study examines whether relative risk perceptions of JUUL vs. smoking are associated with subsequent switching, among smokers who recently initiated JUUL use. Methods: N=16,996 current established smokers who recently purchased a JUUL Starter Kit were followed 6 times over 12 months. Relative 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., odds ratio [OR]=1.48 for “JUUL much less” vs. “more/much more harmful”) and indirect (OR=1.07, for each 10-unit increase in ratio; OR=1.51 for highest (6-100) vs. lowest (0 to <1) ratio categories) relative risk measures (all p<.0001). Among the subset smoking 10+ cigarettes per day, associations between risk perceptions and switching were more pronounced (OR=2.51 for “JUUL much less” vs. “more/much more harmful”; OR=1.81 for 6-100 vs. 0 to <1 ratio, both p<.0001). Conclusions: Smokers who perceive JUUL as less harmful than cigarettes have higher odds of switching. Future research should examine whether messaging which aligns relative risk perceptions with current evidence can facilitate switching, especially among heavier smokers.