JMPF Vol. 9 No.

2 : 109-117
ISSN-p : 2088-8139
ISSN-e : 2443-2946

Perceived Harm and Addictiveness of E-Cigarette: A Systematic

Review

Susi Ari Kristina1*, Ni Putu Ayu Linda Permitasari2, Ahmad Intihan3, Dima Nurrohmah Hayati3, Kharisma
Aprilita Rosyidah3
1.
Department of Pharmaceutics, Faculty of Pharmacy, Universitas Gadjah Mada
2.
Research Assistant, Faculty of Pharmacy, Universitas Gadjah Mada
3.
Master Student in Pharmacy Management, Faculty of Pharmacy, Universitas Gadjah Mada
Submitted: 25-02-2019 Revised: 05-04-2019 Accepted: 20-06-2019
Korespondensi : Susi Ari Kristina : Email : [email protected]

ABSTRACT
The popularity of electronic nicotine delivery systems (ENDS), also known as e-cigarette, has been
growing rapidly in the past years. Therefore, it is also important to explore how e-cigarette users perceive
its harm and addiction risk. The aim of this study is to review and determine perceived harm and
addictiveness of e-cigarette among e-cigarette users. We conducted a systematic review for published
articles in English that had reported about perceived harm and addictiveness of e-cigarette published
during year 2008 to 2018. Relevant studies were located through an extensive search from three
electronic databases (PubMed, Science Direct, and Cochrane Database of Systematic Reviews) and Google
Scholar on October 2018. Key terms used were “perceived harm”, “perceived risk”, “harm and
addictiveness”, “belief”, “electronic cigarette”, “e-cigarette”, and “vaping”. A result of 88 studies were
retrieved and reviewed. After further inspection of references from the collected studies, only 5 selected
studies met all inclusion criteria. The final studies consisted of three cross-sectional studies, one
longitudinal, and one prospective study. E-cigarette were perceived harmless and less addictive than
cigarettes among its users with many predictors associated, including sex, age, race, education,
advertisement and health belief for smoking cessation. Compared to non-users, e-cigarette users were
significantly less likely to worry about the health risks, either its harm or addictiveness. E-cigarette was
perceived harmless and less addictive than tobacco cigarettes. Further study about e-cigarette profile is
particularly important to design public health messages that accurately interpret the scientific data on the
potential harm and addictiveness of e-cigarette.
Keywords: ENDS, e-cigarette, harm, addictiveness.

INTRODUCTION cessation whether e-cigarette promote youth

The use of electronic nicotine delivery uptake of cigarette smoking and the
systems (ENDS), also known as vape pens, regulation9.
vaping devices or e-cigarette, is increasing One of significant concerns of e-
rapidly in some countries1,2. E-cigarette use cigarette use is addiction. E-cigarette liquid
among adolescents has increased over the typically contains nicotine, an addictive
years and has surpassed conventional substance naturally found in tobacco10,11. Other
cigarette smoking3,4. E-cigarette also have been health effect of e-cigarette are also become part
advertised as smoking cessation tools in some of the concern although the long-term health
countries. In public health sector, the long- effects of e-cigarette use are largely unknown.
term effects of e-cigarette use to control Several studies suggest e-cigarette use may
smoking have generated both debate and cause respiratory harm, increased blood
concern due to lack of safety and efficacy pressure, and can interfere with adolescent
data5,6. However, awareness and perceived brain development. Chemicals found in e-
harm of e-cigarette did not show evidence of cigarette aerosol can deposit particles such as
promoting smoking cessation at the nickel, tin, and chromium into the lungs,
population level7,8. The tobacco control causing local respiratory toxicity12.
community is fiercely divided on issues about To date, studies indicate that the
e-cigarette safety and efficacy for smoking majority of e-cigarette users are current or

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 Perceived Harm and Addictiveness of E-Cigarette

Table I. Inclusion and Exclusion Criteria for The Reviewed Articles

Inclusion Criteria Exclusion Criteria

1. Published in the English language 1. Review articles, letters and comments
2. Time frame year from 2008 - 2018 2. Article was not based on original research
3. Report both perceived harm and (i.e., the study was a literature review)
addictiveness of e-cigarette
4. Sample were previous or current users
of e-cigarette in nation/s of study
population
5. Available in full-text

former cigarette smokers, that they use e- Study identification

cigarette to reduce or eliminate cigarette Relevant research studies were located
consumption and perceived e-cigarette as less through an extensive search from three
harmful than cigarettes. Even though there is electronic databases (PubMed, Science Direct,
evidence that e-cigarette are effective in and Cochrane Database of Systematic
reducing or eliminating cigarette Reviews) and Google Scholar on October 2018.
consumption, this finding is not consistent13,14. We conducted a systematic literature search
The role of perceptions and beliefs in behavior for published articles in English that reported
adoption is critical to understanding modes of about perceived harm and addictiveness of e-
intervention and cessation15. As e-cigarette cigarette among e-cigarette users prior to
continue to rise in popularity, it is important to recent years (2008 - 2018).
explore how e-cigarette users on perceptions Preliminary hand search of the
of harm and addiction risk of e-cigarette literature was completed in order to identify
smoking. appropriate keywords. Key terms used for the
The aim of this study is to review and search were as follows: “perceived harm”,
determine perceived harm and addictiveness “perceived risk”, “harm and addictiveness”,
of e-cigarette among e-cigarette users in the “belief”, “electronic cigarette”, “e-cigarette”,
general population worldwide using data “vaping”. Search terms were combined using
obtained from systematic review. This study the operators “AND” and “OR” to ensure that
may provide insights lead to the design of all relevant articles were located. Only articles
more effective campaigns that communicate that had explicitly defined measures those
potential harms and addictiveness of e- variables of interest were included, with
cigarette by analyzing e-cigarette users’ inclusion and exclusion criteria shown in
perceptions regarding e-cigarette smoking. Table I.

METHODS Study quality assessment

This research is a systematic review to About 88 studies were initially collected
find out the perceived harm and addictiveness and reviewed: 84 from the initial search
of e-cigarette among e-cigarette users from strategy and an additional 4 articles were
several related studies. There were 3 main collected from tracking of the literature. After
steps to gain the data; first we identify and further tracking of references from the
select related research about our topic. Second, retrieved studies only 5 studies were finally
we assess the retrieved research that met all analyzed that met all eligibility criteria. Meta-
eligibility criteria. Then third, we made the analytic techniques could not be adequately
review and data extraction for each study. performed because of the limited included

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Figure 1. PRISMA Diagram of Retrieved Studies

and heterogeneity in the method and design sites. We also found a variety of years of
across studies. However, to facilitate our publication within the study, with all study
analysis and discussion, we have grouped the were conducted in recent 5 years (2014 - 2018).
results of the review to examine the The selected studies consisted of three
comparison of perceived harm and cross-sectional studies, one longitudinal study
addictiveness of e-cigarette and conventional and one prospective study. Variation of the
cigarette also perceptions between e-cigarette respondents of study sample came from wide
users and non users. The PRISMA diagram of range of ages and population, start from
retrieved studies (Figure 1). adolescents aged 14 – 18 years, undergraduate
students, young adults and adults aged 18 - 87
Data extraction years. Most of studies using approach by
Data were independently extracted by direct and indirect self-administered
two independent researchers. Data extraction questionnaire and interview either by direct or
form included details of study design, research indirect media to the respondents. The
sample, countries, and selection of variables, methodological characteristics for selected
approach, objectives and the result of each studies of this paper (Table II).
study. Non-agreement or any dissimilarity on
the data extraction was resolved by discussion Perceived harm and addictiveness of e-
among the authors. cigarette
The data extraction about study
RESULTS AND DISCUSSION objectives, perceived harm, addictiveness and
Details of selected studies predictors of e-cigarette use of five selected
The retrieved studies consisted of studies in this systematic review can be seen in
varied number of population and conducted Table III. Information of the participants or
from different countries (US, Texas, North study’s sample was assessed mostly by self-
Carolina, and Minnesota). They were reported questionnaire with specific kind
published from different kind of publication of question related to perceived harm

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Table II. Methodology of Selected Studies

Sample Approach
Study Country Respondents Method Data analysis tools
size
Reinhold US Students at Midwestern 6,037 Cross- SAS version 9.3 Self-reported surv
et al., university between the sectiona
201716 ages of 18–24 l study

Cooper et Texas 6th, 8th and 10th grade 3,704 Cross- Stata 14.1 College Self-reported surv
al., 201619 students’ tobacco use sectiona Station, TX and interview
behaviors l study
Tan et al., US Adults aged 18-87 years 527 Longitu Stata 13 SVY Online survey
201617 dinal
study
Rohde et North Adolescents aged 14–18 69 Cross- SPSS version 23 Phone survey
al., 201812 Carolina who were susceptible to sectiona
or had used any tobacco l study
product

Choi and Minneso Young adults (mean age 1,379 Prospect PC-SAS version 9.2 Computer-assiste
Foster, ta = 24.1 years) from the ive telephone
201418 Minnesota Adolescent study interviews
Community Cohort

studies and addictiveness of e-cigarette among (1.49 - 3.69)18. E-cigarette users had higher
the users. Two out of five studies were used to odds (OR = 4.77, 95% CI: 3.19 – 7.15) of
determining perceptions between of reporting that e-cigarette were “not at all”
e-cigarette and conventional cigarette among harmful to health compared to non e-cigarette
e-cigarette users. Meanwhile three other users from Cooper et al., (2016) study19.
studies were determined the difference of Compared to never-users, e-cigarette ever-
perceived harm and addictiveness of e- users were significantly less likely to worry
cigarette between e-cigarette users and non about the health risks of e-cigarette12.
users. Furthermore about perceived
In Reinhold et al., (2017) study, flavored addictiveness, tobacco cigarettes were
e-cigarette perceived less harmful than perceived as much more addictive than e-
tobacco cigarettes among e-cigarette users cigarette among e-cigarette users16. Choi and
with average perceived harm value 4.49 ± 2.12 Foster (2014) study also stated that
and 6.15 ± 1.70, respectively16. Meanwhile respondents agreed about e-cigarette are less
beliefs about benefits (vaping is less harmful addictive than cigarettes (OR: 1.16, 0.73 -
than smoking and vaping can help people quit 1.85)18. Perception of former e-cigarette users
smoking completely), RR = 2.6 and 4.9 on addiction was lower than non users if using
respectively, p < 0.05), ever users were more vape or e-cigarette everyday (RR 0.2 vs 1.0, p <
likely to agree than never users from Tan et al., 0.0117). Cooper et al., (2016) study stated e-
(2016) study17. Choi and Foster (2014) also cigarette users had higher odds (OR = 1.72;
reported that perceptions of e-cigarette users 95% CI: 1.12 – 2.65) of reporting that e-cigarette
that agreed about e-cigarette are less harmful were “not at all” addictive compared to non
than cigarettes had adjusted OR: 2.34 users19. Compared to never-users, e-cigarette

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Table IIIa. Perceived Harm and Addictiveness of E-Cigarette

Predictors of
Perceived Perceived
Study Objectives perceived harm and
harm addictiveness
addictiveness
Reinhold et To investigate if Flavored e- Flavored e- Being male, ever
al., 201716 advertising cigarette (4.49 ± cigarette (5.61 ± having used an e-
exposure was 2.12) is less 2.17) is less cigarette, ever having
related to harmful than addictive than been a smoker,
perceptions of tobacco tobacco having a mother who
harm, cigarettes (6.15 cigarettes (6.93 ± smoked, and having
addictiveness, ± 1.70) 1.58) seen an
and acceptability advertisement on the
of use of e- internet remained
cigarette in associated with lower
places where perceived harm of e-
traditional cigarette use. Only
cigarettes are being male and
banned lifetime e-cigarette
use were associated
with significantly
lower perceived
addictiveness of e-
cigarette

Cooper et To understand E-cigarette E-cigarette users None of predictors

al., 201619 how e-cigarette users had had higher odds was statistically
are perceived higher odds (OR = 1.72; 95% significant; therefore,
and how these (OR = 4.77, 95% CI: 1.12 – 2.65) all the models
perceptions are CI: 3.19 – 7.15) of reporting that without interactions
associated with of reporting e-cigarette were were used
their decision that e-cigarette “not at all”
whether or not were “not at addictive
to use them all” harmful to compared to
health non users
compared to
non e-cigarette
users
Tan et al., To assess public Beliefs about Perception of Significant correlates
201617 beliefs about e- benefits ever users on for various belief
cigarette’ (vaping is less addiction if items were age, race,
potential harms harmful than using vape or e- education, and health
and benefits smoking), ever cigarette status
users were everyday is
more likely to lower than non
agree (RR = 2.6, e-cigarette users
p < 0.05) than (RR 0.2 vs 1.0, p
never users < 0.01)

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Table IIIb. Perceived harm and addictiveness of e-cigarette

Predictors of
Perceived Perceived
Study Objectives perceived harm and
harm addictiveness
addictiveness
Rohde et al., To examined Compared to Compared to Prior combustible
201812 adolescents’ never-users, e- never-users, e- cigarette use,
knowledge and cigarette ever- cigarette ever- mother’s education,
beliefs about e- users were users less likely and addiction risk
cigarette risks significantly to believe that e- beliefs about e-
less likely to cigarette use cigarette emerged as
worry about would lead to significant predictors
the health risks addiction (M = of adolescents’ e-
of e-cigarette 2.12 vs. M = 3.10, cigarette use. This
(M = 3.18 vs. M p < 0.001) study reveals that
= 3.80, p = knowledge is not
0.031) associated with
adolescent e-cigarette
use, risk beliefs do
predict use
Choi and To identify the Agreed that e- Agreed that e- Given that young
Foster, beliefs cigarette are cigarette are less adults are still
201418 predicting less harmful addictive than developing their
subsequent use than cigarettes cigarettes (OR : tobacco use
of e-cigarette (aOR : 2.34 1.16 (0.73 - 1.85) behaviors, informing
(1.49 - 3.69)) them about the lack of
evidence to support e-
cigarette as quit aids
and the unknown
health risk of e-
cigarette may deter
young adults from
trying these products

RR : relative risk; aOR adjust odds ratio; M : mean

ever-users less likely to believe that e-cigarette associated with significantly lower perceived
use would lead to addiction (Mean 2.12 vs addictiveness of e-cigarette16. Age, race,
3.10, p < 0.001)12. education, and health status also had been
There were some predictors associated significant correlates for various belief items of
with perceived harm and addictiveness of e- e-cigarette users17. Prior combustible cigarette
cigarette from the selected studies. Being male, use, mother’s education, and addiction risk
ever having used an e-cigarette, ever having beliefs about e-cigarette emerged as significant
been a smoker, having a mother who smoked, predictors of adolescents’ e-cigarette use from
and having seen an advertisement on the Rohde et al., 2018 study12. Given that young
internet remained associated with lower adults are still developing their tobacco use
perceived harm of e-cigarette use. Only being behaviors, informing them about the lack of
male and lifetime e-cigarette uses were evidence to support e-cigarette as quit aids

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and the unknown health risk of e-cigarette choice27, especially for youth and young
may deter young adults from trying these adults.
products18. There were some predictors associated
E-cigarette represent a new way to with perceived harm and addictiveness of e-
administer substances to the respiratory cigarette based on our review, including sex,
tract20, using battery power to heat an element age, race, education, and health belief for
and disperse a solution that usually contains smoking cessation. Psychosocial factors like
nicotine. The dispersion of the solution leads home use of each product, friends’ use,
to the create an aerosol that can be inhaled by positive attitudes toward e-cigarette and
the user21. The main differences between e- participant perception of the harm of e-
cigarette and tobacco cigarettes are cigarette were have strongly positive
expectation to largely determine potential risk association both with e-cigarette and cigarette
discrepancies of the combustion. Other than use28. Another study state that college students
nicotine, the ingredients of e-cigarette liquids perceive e-cigarette as less addictive than
are compounds that have been used tobacco cigarette is concerning because among
extensively in food, pharmaceutical and adolescents, intention to use cigarette has been
cosmetic products. There is limited evidence found to be highly correlated with perceived
from clinical studies about the effects of addictiveness29. Initial hopes that e-cigarette
inhaling those compounds22. would be both a less toxic competitor to
The safety and risk profile of e-cigarette cigarette and help people to quit smoking have
is particularly important, because e-cigarette not translated into real-world positive effects.
have been on the market for few years and the Instead, e-cigarette have simply become
long-term population health effects are another class of tobacco products that are
unknown23. Based on our review, most e- maintaining and expanding the tobacco
cigarette users from the selected study stated epidemic21.
that e-cigarette was perceived less harm than Potential limitations need to be
tobacco cigarettes. The study highlights the addressed in interpreting the findings of this
need to design public health messages that review, including heterogeneity of the studies’
accurately interpret the scientific data on the method made it challenging in summarizing
potential harm of e-cigarette and clearly the review. Based on our findings, study about
differentiate the absolute from the relative perceived harm and addictiveness of e-
harm of e-cigarette24. cigarette was still limited, especially study
Our review also found that most from developing countries which also may the
respondents state that e-cigarette was factor of this review cannot generally
perceived less addictive than tobacco represent the issue in that region. Therefore,
cigarettes among e-cigarette users. Long-term we are suggesting more e-cigarette harm and
nicotine addiction is a concern for many health addictiveness study will conduct with an
professionals and some smokers themselves25. accurate and particular method in the near
In 2016, FDA announced its final rule to future. Further research should address the
regulate e-cigarette under the “Family scientific uncertainty surrounding the use e-
Smoking Prevention and Tobacco Control cigarette30,31 and consider means to clearly
Act”, which outlines options for the regulation convey information about its harm and
of e-cigarette, particularly as they relate to addiction risk.
youth and young adults, based on successful
smoking policies26. Whilst it is acknowledged CONCLUSION
that more research is needed into the Our review conclude that e-cigarette
constituents and long-term effects of e- were perceived less harm and less addictive
cigarette, because public deserve an accurate than tobacco cigarettes among e-cigarette
and evidence based in order to inform their users than non users. There were many

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