Smokers have strong support for many e-cigarette policies

The proposal made by the FDA last April would require e-cigarette makers to register their products with the FDA, make an application to market the devices, use a nicotine addiction warning label and create a minimum purchase age, along with other requirements. While previous research has captured e-cigarette use and awareness, there is little data on e-cigarette policy perceptions. Olivia A. Wackowski, PhD, MPH, assistant professor of health education and behavioral science in the Center for Tobacco Studies at the School of Public Health and member of the Cancer Institute's Cancer Prevention and Control Program, and Cristine Delnevo, PhD, MPH, co-leader of the Cancer Institute's Cancer Prevention and Control Program and director of the Center for Tobacco Studies further examined smokers' attitudes on such policies. Their work appears in the current online edition of Tobacco Control.

The authors used nationally representative data from an online survey that captured 519 current smokers during a two-week period in April 2014, just prior to the announcement of the FDA's proposed rule. Current smokers were adults who ever smoked 100 tobacco cigarettes and now smoke some days or every day. Nearly half (46 percent) of these participants were also current e-cigarette users. Those participants were defined as smokers who had used e-cigarettes in the past 30 days. Former e-cigarette users made up 62 percent of the overall tobacco smoking group and were defined as those who had ever tried the devices but had not used them in the past 30 days.

Respondents were asked if they ever heard of e-cigarettes prior to the survey and how harmful they believed them to be compared to tobacco cigarettes. They were also asked whether they agreed or disagreed with banning e-cigarette advertising where advertising for tobacco cigarettes is banned, placing a warning label on e-cigarettes for potential risks like other tobacco products have, and regulation of e-cigarettes by the FDA.

Overall, researchers found that while 90 percent of respondents were aware of e-cigarettes, nearly two-thirds (62.5 percent) did not know the devices are unregulated. A majority (83.5 percent) of all respondents also agreed that e-cigarettes should be FDA regulated. This number included 77.9 percent of current e-cigarette users. Nearly 87 percent of all respondents and 78 percent of e-cigarette users agreed that e-cigarettes should carry warning labels about potential risks, and a majority of respondents also agreed the devices should have the same legal age of sale as other tobacco products (87.7 percent all respondents; 91.8 percent current e-cigarette users).

"One finding of note in this work is that nearly two-thirds of respondents did not realize e-cigarettes are not regulated under any government agency -- possibly leading to a false sense of security about the safety of the devices. But when respondents were prompted, a vast majority of them believed they should be regulated by the FDA for both quality and safety. As the FDA prepares to issue a final rule regarding e-cigarette regulation, it is important to have such data," notes Dr. Wackowski, who is the lead author and principal investigator of the study.

More than half (55.5 percent) also supported advertising restrictions for the devices. "Exposure to tobacco advertising is a risk factor for youth tobacco use and while cigarette marketing is considerably restricted in the U.S., e-cigarette companies have no such restrictions and spend millions advertising their products in magazines, at promotional events and on TV. Youth e-cigarette experimentation is rising, and so it is encouraging that there is support to restrict e-cigarette advertising," says Dr. Delnevo, study co-author and professor and chair of health education and behavioral science at the School of Public Health. The research also showed that support was lower for policies restricting flavoring of e-cigarettes (44.3 percent) and restriction of indoor use of e-cigarettes (41.2 percent). However, authors note that support for indoor e-cigarette restrictions could increase over time, similarly to how smokers' support for policies to ban indoor smoking of tobacco cigarettes has increased with time and with the passage of such policies.

"It was also interesting to find in this study that even though smokers largely believe e-cigarettes are less harmful than tobacco cigarettes, almost 90 percent nevertheless agreed that e-cigarettes should carry warning labels, something they are not required to do at the moment," Wackowski added. The FDA's regulatory proposal only suggests one nicotine addiction warning, and Wackowski aims to develop and pilot test a series of warnings that may be appropriate for e-cigarettes in a new research project funded by the FDA's Center for Tobacco Products. The authors also note future studies may also want to measure policy attitudes with larger samples and examine the attitudes of non-smokers. They also recommend further exploration on other policy issues such as e-cigarette taxation and internet sales and how policy perceptions correlate with knowledge and beliefs about e-cigarettes.