Authors: Emma Jankowski, Rebecca Henderson, Elle Elson, Alysha Ennis, Sydney Galusha, Grace Turk, Hayley Curran, Phoenix Matthews, Elizabeth Klein, Darren Mays, Theodore Wagener, Mike Pennell, Paul Nini, Mike Slater, Amy Ferketich, and Joanne G. Patterson
Poster presented at the 2023 CASEL Tobacco Regulatory Science Conference
INTRODUCTION
- Sexual and Gender Minority Young Adults (SGM YA) report higher dual use rates (smoking and vaping nicotine) than non-SGM YA. (1-6)
- National tobacco risk communications have been proven to be successful at increasing knowledge about the harms of tobacco and decreasing use. (7-18)
- No studies describe effective anti-tobacco message framing for SGM and non-SGM YA engaged in dual use, though understanding these nuances is important for developing inclusive anti-tobacco communications.
- We tested absolute risk (AR; describing shared health harms of smoking and vaping) vs. comparative risk messages (CR; describing comparative health harms of smoking vs. vaping).
HYPOTHESIS
- Messages emphasizing comparative (vs absolute) risk of dual use will most effectively increase tobacco risk perceptions.
METHODS
- Through a mixed-methods, formative evaluation we iteratively developed absolute risk messages (AR; describing shared health harms of smoking and vaping) and comparative risk messages (CR; describing comparative health harms of smoking vs. vaping).
- For focus groups (N=3 groups; N=12 participants) and in-depth interviews (N=13), participants responded qualitatively to a randomized series of AR/CR messages on FDA regulatory topics.
- In an online rating survey (N=326), participants viewed 5 randomly selected AR/CR messages from a total of 24, which they rated for perceived message effectiveness (PME; Range: 1-5) and psychological reactance (Range: 1-5).
RESULTS
Qualitative Codebook for Focus Groups with Young Adults
| Theme | Code | Definition | N (%) of all statements |
| Content | Facts/statistics | Discusses the use of facts and statistics as an effective health communication tactic | 32 (12.12%) |
| Fear=effective | Discusses “fear” as an effective health communication tactic. May also use words like “scary” or “afraid” | 27 (10.23) | |
| Shock value | Discusses “shock value” as an effective health communication tactic. Participants may discuss being “surprised” by a message, making it effective | 6 (2.27%) | |
| Novelty=effective | Discusses “novelty” (i.e.., a new idea, or new information) as an effective health communication tactic | 23 (8.71%) | |
| Short + simple | Discusses short+simple is an effective health communication tactic, either by saying a message would be better short or simpler, or liking a message for that reason | 18 (6.82%) | |
| Personal experience | Discusses how their personal experience (either their own smoking or a peer/loved one) influences their perceptions of the message | 6 (2.27%) | |
| Addictiveness relative to other drugs | Discusses the addictiveness or harms of nicotine/tobacco relative to other illicit drugs or alcohol use | 6 (2.27%) | |
| Relative risk ecig v. cig | Discusses the relative risk of using e-cigarettes versus combustible cigarettes (or the messaging around relative risk) | 23 (8.71%) | |
| Rate reduction | Discusses using information on how to decrease smoking on the path to quitting | 18 (6.82%) | |
| Permissive | Discusses how messaging/content is permissive (i.e., makes it seem fine to use) either vaping or cigarette smoking, or both | 12 (4.55%) | |
| Off- ramp | Discusses building an “off ramp” (i.e., steps to quitting smoking, potentially including what to do once you know smoking is bad for you) is important content to include | 7 (2.65%) | |
| Language | Vape=universal language | Language of “vape” or “vaping” is considered universal (used by everyone/the “norm”) | 9 (3.41%) |
| Lay language | Discusses how using “lay” or “everyday” language is effective (e.g., heart disease vs. CVD). | 6 (2.27%) | |
| Product specific language | Discusses how using product-specific language (e.g., formaldehyde vs. toxic chemical) is effective | 6 (2.27%) | |
| Audience matters | Discusses how the message is effective for targeted audience | 17 (6.44%) | |
| General audience | Discusses using language to appeal to a general audience | 12 (4.55%) | |
| Person-forward language | Discusses using person-forward language (e.g., people who smoke) vs product-forward language (e.g., smoker) | 14 (5.30%) |
Qualitative Codebook for Interviews with Young Adults
| Theme | Code | Definition | N (%) of all statements |
| Message Framing | short + simple | discusses short + simple is an effective health communication tactic, either by saying a message would be better short or simpler, or liking a message for that reason | 17 (2.62%) |
| facts/statistics = effective | discusses facts and statistics as an effective health communication tactic | 17 (2.62%) | |
| facts/statistics = ineffective | discusses facts and statistics as NOT or LESS effective | 9 (1.39%) | |
| constituents = effective | discusses mentioning toxic constituents (formaldehyde, etc.) as effective | 28 (4.31%) | |
| constituents = ineffective | discusses toxic constituents as NOT or LESS effective | 9 (1.39%) | |
| fear = effective | discusses “fear” as effective. May also use words like “scary” or “afraid.” | 17 (2.62%) | |
| fear = ineffective | discusses “fear” as NOT or LESS effective | 2 (0.31%) | |
| shock value = effective | discusses “shock value” as effective. Participants may discuss being “surprised” by a message, making it effective. | 4 (0.62%) | |
| shock value = ineffective | discusses “shock value” as NOT being effective | 2 (0.31%) | |
| novelty = effective | discusses “novelty” (i.e.., a new idea, or new information, “outside the box” thinking) as effective | 32 (4.93%) | |
| novelty = ineffective | discusses “novelty” (i.e.., a new idea, or new information, “outside the box” thinking) as effective | 7 (1.08%) | |
| known truths = effective | discusses how “knowing” that something is “true” (e.g., smoking causes cancer) makes the message more effective (vs. something novel/new/unheard of) | 39 (6.01%) | |
| known truths = ineffective | discusses how “knowing” that something is “true” (e.g., smoking causes cancer) makes the message NOT or LESS effective (vs. something novel/new/unheard of) | 24 (3.70%) | |
| secondary effects=effective | discusses how referencing health harms or other impacts of smoking/vaping (e.g., financial) on family/friends/bystanders is effective | 2 (0.31%) | |
| Contextual Factors | real-life context | discusses how real-life context or current events (e.g., opioid epidemic, COVID) influences their perceptions of the message | 4 (0.62%) |
| personal experience | discusses how personal experience (either their own smoking or a peer/loved one) influences their perceptions of the message | 53 (8.17%) | |
| prior quit attempts | discusses how a history of prior quit attempts influences their perceptions of the message | 3 (0.46%) | |
| audience | discusses how audience (i.e., whether target audience is smokers/vapers; established/not established users; adolescents, young or older adults) influences how effective or acceptable the message is | 74 (11.40%) | |
| Product and Product Use Factors | comparative risk vapes vs. cigarettes | discusses the comparative risk of vaping versus smoking combustible cigarettes (or the messaging around comparative risk) | 7 (1.08%) |
| equivalent risk | discusses how smoking/vaping has similar risks; or how referencing smoking/vaping in same statement makes the risk seem equivalent | 13 (2.00%) | |
| modified risk | discusses nicotine/vaping as a modified risk (healthier or lower harm) product than traditional combustible tobacco | 32 (4.93%) | |
| general health | Discusses general health when viewing the message; generally discusses how the message evoked a thought about addiction, whether positive or negative. | 46 (7.09%) | |
| general addictiveness | Discusses general addictiveness when viewing the message; generally discusses how the message evoked a thought about addiction, whether positive or negative. | 35 (5.39%) | |
| harm reduction | discusses using nicotine/tobacco as a harm reduction strategy (i.e., Instead of other drug use, to manage mental health/stress) | 4 (0.62%) | |
| switching | discusses using “switch” language to describe vaping in lieu of smoking. May use terms including, but not limited to: “turn to,” “change over,” “substitute,” “alternative,” or “use instead”. | 9 (1.39%) | |
| rate reduction | discusses using information on how to decrease smoking on the path to quitting | 14 (2.16%) | |
| offramp | generally discussed building an “off ramp” (i.e., steps to quitting smoking, potentially including what to do once you know smoking is bad for you) is important content to include | 17 (2.62%) | |
| Language | permissive | discusses how messaging/content is permissive (i.e., makes it seem fine to use) either vaping or cigarette smoking, or both. | 36 (5.55%) |
| tone | discusses the tone of the message (e.g., “preachy” “friendly” etc.) | 27 (4.16%) | |
| lay language | discusses how using “lay” or “everyday” language is effective (e.g., heart disease vs. CVD). | 1 (0.15%) | |
| scientific language | discusses how using “scientific” or “professional” language is effective (e.g., cardiovascular disease vs. heart disease) | 6 (0.92%) | |
| specific language = effective | discusses how using more specific language is effective (e.g., lung injury vs. wheezing) | 22 (3.39%) | |
| broad language = effective | discusses how using broader language is effective (e.g., lung injury vs. wheezing) | 7 (1.08%) | |
| person-forward language | discusses using person-forward language (e.g., people who smoke or “using cigarettes” [Implied person]) vs product-forward language (e.g., smoker) | 2 (0.31%) | |
| general audience | discusses using language to appeal to a general audience | 1 (0.15%) |
Results from the Online Rating Survey
| PME- Cigarettes | PME- Vaping | Reactance | ||||||||||||||||||||
| LGBTQ | Non-LGBTQ | LGBTQ | Non-LGBTQ | LGBTQ | Non-LGBTQ | |||||||||||||||||
| ID# | Msg Type | Message | M | LL | UL | M | LL | UL | M | LL | UL | M | LL | UL | M | LL | UL | M | LL | UL | ||
| 7 | AR | Cigarettes and vapes contain nicotine. Nicotine is an addictive chemical. | 2.00 | 0.18 | 3.82 | 3.11 | 2.67 | 3.56 | 2.85 | 2.39 | 3.31 | 3.10 | 2.66 | 3.54 | 1.61 | 1.35 | 1.88 | 1.79 | 1.49 | 2.09 | ||
| 6 | AR | Even occasional smoking and vaping can lead to nicotine addiction. | 2.62* | 2.17 | 3.06 | 3.68* | 3.26 | 4.10 | 2.59* | 3.01 | 3.91 | 3.46* | 2.11 | 3.07 | 2.04 | 1.66 | 2.42 | 2.11 | 1.73 | 2.50 | ||
| 10 | AR | Can’t sleep? Nicotine in cigarettes and vapes can lead to sleep problems, including insomnia. | 3.17 | 2.69 | 3.64 | 3.73 | 3.31 | 4.14 | 3.04 | 2.56 | 3.52 | 3.41 | 2.99 | 3.82 | 2.13 | 1.73 | 2.53 | 1.95 | 1.59 | 2.30 | ||
| 4 | AR | Nicotine doesn’t cause cancer, but toxic chemicals in e-liquid and tobacco can. | 3.42 | 2.97 | 3.88 | 3.12 | 2.60 | 3.64 | 3.29 | 2.82 | 3.76 | 3.09 | 2.60 | 3.58 | 2.08 | 1.70 | 2.46 | 2.48 | 2.07 | 2.90 | ||
| 2 | AR | Most people think smoking cigarettes and vaping nicotine are harmful to your health. They’re right. | 3.44 | 2.98 | 3.89 | 3.54 | 3.12 | 3.96 | 3.41 | 2.95 | 3.86 | 3.33 | 2.89 | 3.78 | 2.05 | 1.70 | 2.41 | 1.99 | 1.70 | 2.28 | ||
| 12 | AR | Can’t find your keys? Nicotine in cigarettes and vapes can harm your brain and lead to memory loss. | 3.45 | 3.08 | 3.82 | 3.53 | 3.07 | 4.00 | 3.19 | 2.79 | 3.61 | 3.41 | 2.94 | 3.87 | 2.83 | 2.42 | 3.25 | 2.74 | 2.33 | 3.15 | ||
| 8 | AR | Smoking cigarettes and vaping nicotine damages your DNA and increases your risk for cancer. | 3.76 | 3.37 | 4.15 | 4.09 | 3.75 | 4.43 | 3.39 | 2.94 | 3.84 | 3.63 | 3.18 | 4.09 | 2.41 | 1.98 | 2.84 | 2.11 | 1.69 | 2.53 | ||
| 5 | AR | Using cigarettes and nicotine vapes exposes you to heavy metals— like arsenic and lead. | 3.85 | 3.47 | 4.24 | 3.90 | 3.52 | 4.28 | 3.74 | 3.42 | 4.06 | 3.51 | 3.06 | 3.96 | 1.77 | 1.44 | 2.10 | 2.15 | 1.81 | 2.50 | ||
| 11 | AR | Wheezing lately? Smoking cigarettes and vaping nicotine increases your risk for lung problems. | 3.94 | 3.48 | 4.40 | 3.86 | 3.42 | 4.29 | 3.53 | 3.01 | 4.05 | 3.39 | 2.90 | 3.89 | 1.96 | 1.58 | 2.34 | 1.82 | 1.52 | 2.12 | ||
| 3 | AR | Cigarettes and some nicotine vapes contain formaldehyde, a chemical that causes cancer. | 4.07 | 3.72 | 4.42 | 3.90 | 3.48 | 4.32 | 3.66 | 3.23 | 4.08 | 3.65 | 3.23 | 4.06 | 1.88 | 1.54 | 2.22 | 1.87 | 1.56 | 2.18 | ||
| 9 | AR | Smoking cigarettes and vaping nicotine increases your risk for heart disease. | 4.34 | 4.1 | 4.59 | 4.07 | 3.65 | 4.49 | 3.59 | 3.15 | 4.04 | 3.73 | 3.26 | 4.19 | 1.80 | 1.44 | 2.16 | 1.96 | 1.55 | 2.38 | ||
| 1 | CR | Nicotine vapes are not a safe alternative to cigarettes. | 2.86 | 2.33 | 3.39 | 2.66 | 1.45 | 3.16 | 3.08 | 2.51 | 3.65 | 3.75 | 3.33 | 4.16 | 2.33 | 1.87 | 2.80 | 1.99 | 1.61 | 2.37 | ||
| 24 | CR | Can’t find your keys? Research suggests that vaping nicotine can improve attention and memory during smoking abstinence. | 2.69 | 2.21 | 3.17 | 2.60 | 2.16 | 3.04 | 1.93 | 1.54 | 2.32 | 2.06 | 1.64 | 2.47 | 3.30 | 2.88 | 3.73 | 3.41 | 3.00 | 3.82 | ||
| 22 | CR | Can’t sleep? People who vape and smoke report more sleep problems than those who only vape. | 3.38 | 2.99 | 3.78 | 3.01 | 2.46 | 3.56 | 2.09 | 1.69 | 2.50 | 2.30 | 1.80 | 2.80 | 2.32 | 1.96 | 2.69 | 2.60 | 2.11 | 3.08 | ||
| 14 | CR | Many people think vaping nicotine is just as harmful as smoking cigarettes. Truth is, nicotine vapes are less harmful than cigarettes. | 3.46 | 3.00 | 3.91 | 3.71 | 3.32 | 4.10 | 1.98 | 1.54 | 2.41 | 2.11 | 1.75 | 2.47 | 2.18 | 1.79 | 2.57 | 2.47 | 2.06 | 2.89 | ||
| 19 | CR | Nicotine vapes are addictive, but people who vape and smoke tobacco are 7 times more likely to be addicted to nicotine than those who only vape. | 3.50 | 3.09 | 3.92 | 3.51 | 3.12 | 3.90 | 2.63 | 2.25 | 3.02 | 2.52 | 2.11 | 2.93 | 1.94 | 1.54 | 2.33 | 2.40 | 1.99 | 2.81 | ||
| 18 | CR | Vaping heats nicotine, resulting in lower levels of harmful chemicals than burned tobacco in cigarettes. | 3.52 | 3.03 | 4.00 | 3.63 | 3.24 | 4.03 | 2.38 | 1.89 | 2.87 | 2.33 | 1.90 | 2.77 | 2.28 | 1.85 | 2.71 | 2.14 | 1.78 | 2.50 | ||
| 13 | CR | Vaping nicotine is harmful to your health, but it is less harmful than smoking. | 3.71 | 3.25 | 4.17 | 3.77 | 3.43 | 4.11 | 2.39 | 1.96 | 2.82 | 2.48 | 2.08 | 2.89 | 2.02 | 1.65 | 2.39 | 2.46 | 2.15 | 2.78 | ||
| 21 | CR | People who smoke cigarettes and vape nicotine have a higher risk of developing heart disease than those who only vape. | 3.73 | 3.33 | 4.13 | 4.07 | 3.66 | 4.49 | 2.46 | 1.93 | 3.00 | 3.03 | 2.57 | 3.48 | 1.96 | 1.57 | 2.35 | 2.07 | 1.72 | 2.43 | ||
| 17 | CR | Using cigarettes and nicotine vapes exposes you to more heavy metals—like arsenic and lead—than if you only vape. | 3.82 | 3.43 | 4.21 | 3.50 | 2.95 | 4.05 | 3.06 | 2.61 | 3.52 | 2.90 | 2.34 | 3.47 | 2.13 | 1.74 | 2.53 | 2.18 | 1.72 | 2.64 | ||
| 23 | CR | Wheezing much? People who smoke cigarettes and vape nicotine report more lung problems than those who only vape. | 3.89 | 3.51 | 4.28 | 4.35 | 4.09 | 4.61 | 3.11 | 2.64 | 3.59 | 3.23 | 2.69 | 3.77 | 2.11 | 1.78 | 2.44 | 2.13 | 1.70 | 2.56 | ||
| 16 | CR | Many people think nicotine in vapes and cigarettes causes cancer. Truth is, toxic chemicals in burning cigarettes are more likely to cause cancer. | 3.97 | 3.58 | 4.36 | 3.78 | 3.36 | 4.20 | 2.63 | 2.19 | 3.07 | 2.63 | 2.10 | 3.16 | 1.88 | 1.56 | 2.20 | 2.38 | 1.96 | 2.80 | ||
| 15 | CR | Cigarettes contain more cancer-causing chemicals—like formaldehyde—than nicotine vapes. | 4.01 | 3.60 | 4.42 | 4.13 | 4.42 | 4.48 | 2.10 | 1.71 | 2.50 | 2.53 | 2.04 | 3.01 | 1.95 | 1.59 | 2.31 | 1.84 | 1.49 | 2.18 | ||
| 20 | CR | Smoking cigarettes can increase your risk for lung, head, and neck cancer. Using nicotine vapes only may decrease your cancer risk. | 4.04 | 3.69 | 4.39 | 3.94 | 3.48 | 4.39 | 2.34 | 1.85 | 2.84 | 2.34 | 1.88 | 2.81 | 2.11 | 1.63 | 2.59 | 2.58 | 2.11 | 3.04 | ||
- LGBTQ+ YA qualitatively described long-term physical harms (i.e., cancer) as effective.
- Non-LGBTQ+ YA described novel messaging (i.e., insomnia, heart disease) as effective.
- CR messages positively resonated with LGBTQ+ participants due to their implied harm reduction focus; however, non-LGBTQ+ YA expressed concern about CR messages being permissive for vaping.
- LGBTQ+ YA described high-threat messages with “shock value” statements as effective.
- Quantitatively, AR and CR messages scored PMEs above three, indicating promise for influencing cigarette smoking. Messages with greatest PME scores addressed heart and lung disease, toxic constituents, and cancer.
- All messages scored below 3 for reactance, indicating low risk for counterarguing.
CONCLUSIONS
- Overall, participants responded positively to AR/CR messages including short and long-term health effects.
- LGBTQ+ participants responded more positively to CR messages, which may reflect community experiences with minority stress and coping.
- Experimental studies testing the long-term effect of exposure to AR/CR messages on dual use among LGBTQ+ YA are needed.
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SUPPLEMENTAL MATERIALS
Messages Shown to Interview Participants
RR-Tox3: Using cigarettes and nicotine vapes exposes you to more heavy metals—like arsenic and lead—than if you only vape.
RR-Tox2: Many people think nicotine in vapes and cigarettes causes cancer. Truth is, toxic chemicals in burning cigarettes are more likely to cause cancer.
RR-PhysL2: People who smoke cigarettes and vape nicotine have a higher risk of developing heart disease than those who only vape.
RR-PhysL1: Smoking cigarettes can increase your risk for lung, head, and neck cancer. Using nicotine vapes only may decrease your cancer risk.
RR-Tox1: Cigarettes contain more cancer-causing chemicals—like formaldehyde—than nicotine vapes.
RR-Soc1: Many people think vaping nicotine is just as harmful as smoking cigarettes. Truth is, nicotine vapes are less harmful than cigarettes.
RR-Gen1: Vaping nicotine is harmful to your health, but it is less harmful than smoking.
RR-PhyS3: Can’t find your keys? Research suggests that vaping nicotine can improve attention and memory during smoking abstinence.
RR-Addict1: Nicotine vapes are addictive, but people who vape and smoke tobacco are 7 times more likely to be addicted to nicotine than those who only vape.
RR-PhysS2: Wheezing much? People who smoke cigarettes and vape nicotine report more lung problems than those who only vape.
RR-PhysS1: Can’t sleep? People who vape and smoke report more sleep problems than those who only vape.
RR-Tox 4: Vaping heats nicotine, resulting in lower levels of harmful chemicals than burned tobacco in cigarettes.
AR-PhyL1: Smoking cigarettes and vaping nicotine damages your DNA and increases your risk for cancer.
AR-Tox2: Nicotine doesn’t cause cancer, but toxic chemicals in e-liquid and tobacco can.
AR-PhyS2: Wheezing lately? Smoking cigarettes and vaping nicotine increases your risk for lung problems.
AR-Gen 1: Nicotine vapes are not a safe alternative to cigarettes.
AR-PhyL2: Smoking cigarettes and vaping nicotine increases your risk for heart disease.
AR-Addict1: Even occasional smoking and vaping can lead to nicotine addiction.
AR-Addict2: Cigarettes and vapes contain nicotine. Nicotine is an addictive chemical.
AR-Tox3: Using cigarettes and nicotine vapes exposes you to heavy metals—like arsenic and lead.
AR-PhysS1: Can’t sleep? Nicotine in cigarettes and vapes can lead to sleep problems, including insomnia.
AR-Tox1: Cigarettes and some nicotine vapes contain formaldehyde, a chemical that causes cancer.
AR-Soc1: Most people think smoking cigarettes and vaping nicotine are harmful to your health. They’re right.
AR-PhyS3: Can’t find your keys? Nicotine in cigarettes and vapes can harm your brain and lead to memory loss.
Messages shown to Focus Group Participants
T1a: Cigarette smoke contains 69 cancer-causing chemicals.
T1b: Cigarette smoke contains 69 chemicals known to cause cancer.
T2a: Cigarette smoke AND e-cigarette vapor contains cancer-causing chemicals, including formaldehyde.
T2b: Cigarette smoke AND e-cigarette vapor contains chemicals that cause cancer, including formaldehyde.
T3: E-cigarette vapor and tobacco smoke contains carbon monoxide–a deadly toxin that deprives your heart of oxygen.
P1: Smoking cigarettes increases your risk for lung, head and neck, and other tobacco related cancers.
P2: 1 in 5 people die each year from smoking cigarettes.
P3a: Using both e-cigarettes and traditional cigarettes can increase your risk for cardiovascular disease.
P3b: Using both e-cigarettes and traditional cigarettes can increase your risk for heart disease.
P4a: Dual users of traditional cigarettes and e-cigarettes experience recurring respiratory issues—including wheezing, coughing, and excess phlegm.
P4b: Use e-cigarettes and traditional cigarettes can increase your risk for multiple respiratory issues—including wheezing, coughing, and excess phlegm.
P4c: Young people who vape nicotine and smoke cigarettes experience recurring respiratory issues—including wheezing, coughing, and excess phlegm.
P4d: Young adults who vape and smoke cigarettes experience recurring respiratory issues—including wheezing, coughing, and excess phlegm.
P4e: Smokers who also vape experience recurring respiratory issues— including wheezing, coughing, and excess phlegm.
A1a: Approximately 2 in 3 cigarette smokers are dependent on nicotine.
A1b: Approximately 2 in 3 smokers are addicted to nicotine.
A1c: Approximately 2 in 3 tobacco users are nicotine dependent.
A2a. All tobacco products contain nicotine—a highly addictive chemical.
A2b. All tobacco products contain nicotine—an addictive chemical.
A2c. All tobacco products contain nicotine—an addictive chemical that causes insomnia.
Ad. All tobacco products contain nicotine—an addictive chemical that increases heart rate and blood pressure.
RRT1a: Cigarettes contain 9 times more cancer-causing chemicals than e-cigarettes.
RRT1b: Cigarettes contain 9 times more cancer-causing chemicals than nicotine vapes.
RRT1c: There are 9 times more cancer-causing chemicals in cigarettes than nicotine vapes.
RRT2: Cigarettes contain more cancer-causing chemicals— like formaldehyde— than e-cigarettes.
RRT3a: Carbon monoxide-–a deadly toxin that deprives your heart of oxygen-–is higher in dual users of traditional cigarettes and e-cigarettes.
RRT3b: Carbon monoxide-–a deadly toxin that deprives your heart of oxygen-–is higher in people who smoke and vape nicotine.
RRT3c: Carbon monoxide-–a deadly toxin that deprives your heart of oxygen-–is higher in people who smoke cigarettes and vape.
RRP1: Smoking cigarettes and other tobacco products can increase your risk for lung, head and neck, and other tobacco related cancers.
RRP2: 1 in 5 people die each year from smoking cigarettes and other tobacco products.
RRP3: Smokers who also vape nicotine are more likely to develop cardiovascular disease.
RRP4a: Dual users of traditional cigarettes and e-cigarettes experience more respiratory issues—including wheezing, coughing, and phlegm—than people who use e-cigarettes only.
RRP4b: People who smoke and vape experience more respiratory issues— including wheezing, coughing, and phlegm—than people who use e- cigarettes only.
RRA1: People who vape and use cigarettes are 7 times as likely to be addicted to nicotine than those who only vape.
RRA2: Both combustible tobacco and e-cigarettes contain nicotine—a highly addictive chemical.