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Turiel and colleagues divided norms into two kinds: Moral norms and conventional norms. Moral norms are universal, concerned with welfare, justice, fairness, equality and/or rights, and rule/authority independent. Conventional norms are local, rule/authority dependent, and concerned with maintaining social coordination, preserving tradition, and avoiding punishment. This account has been challenged, and the existence of a crisp distinction remains debatable. In this paper, I defend a version of the moral/conventional distinction on the basis that people generally judge norms concerned with welfare violations as moral, and that they distinguish between the morality of the action and that of the agent. I argue that we can make sense of the mixed data because people differ in how they perceive harm. Harm perception, rather than “objective” harm, is the relevant variable in knowing how people judge norms. To illustrate this, I explore why people perceive norms differently and how the moral/conventional distinction is reflected not only between cultures, but within them too. This should prompt us to reimagine the moral/conventional distinction to account for this diversity in perceptions. Doing away with the distinction risks misrepresenting both inter- and intra-cultural diversity in perceptions of harm. [ABSTRACT FROM AUTHOR]

PurposePerceived harm is associated with substance use. Changes in product and policy landscapes may impact perceived harms of tobacco and cannabis. This study aimed to examine changes in young adults' perceived harms of tobacco and cannabis and their associations with use behavior during a period including both before and after legalization of cannabis.MethodsWe conducted a panel survey of California Bay Area young adults (mean age = 23.5 years old, 64.4% female) in 2014 and 2019-2020. Participants (N = 306) reported past 30-day use and perceived harms of tobacco and cannabis at both waves. Perceived harms to health of cannabis and tobacco (cigarettes, e-cigarettes, hookah, smokeless tobacco, and secondhand tobacco smoke) were measured from 1-"Not at all harmful" to 7-"Extremely harmful." Mixed-effects logistic regressions examined associations between perceived harms and use of tobacco and cannabis, controlling for demographics.ResultsParticipants perceived lower harm for cannabis than for tobacco products. Perceived harms of e-cigarettes, hookah, and smokeless tobacco significantly increased over time; while perceived harms of cigarettes, secondhand tobacco smoke, and cannabis did not change. Increased perceived harm of e-cigarettes was associated with lower odds of any tobacco use (OR = 0.72, 95%CI = 0.56, 0.92), and increased perceived harm of cannabis was associated with lower odds of any cannabis use (OR = 0.51, 95%CI = 0.42, 0.62).ConclusionsFindings suggest that perceived harms of e-cigarettes and cannabis play important roles in driving young adult use behaviors. Risk communication efforts that increase perceptions of health harms related to e-cigarettes and cannabis may decrease use of tobacco and cannabis among young people.

Introduction Cigarette smoking and smoking-related lung disease are more common in rural (vs urban) areas of the United States (US). This study examined relationships between geographical location, cigarette risk perceptions, and current smoking among older adults who are at greatest risk of developing smoking-related lung disease. Methods The study was a secondary data analysis of 12126 respondents aged ≥40 years from Wave 5 of the Population Assessment of Tobacco and Health Study. Weighted descriptive statistics and Poisson regressions assessed current smoking (vs never or former) as a function of geographical location in a stepwise fashion, first unadjusted, then adjusting for sociodemographic characteristics, and finally for both sociodemographic characteristics and cigarette risk perceptions (4-item scale), in three separate models. Sensitivity analyses examined whether individual risk perceptions items had a greater impact on the association between geographical location and current smoking. Results Current smoking was more common among rural (20.6%) than urban (17.6%) residents. The risk ratio (RR) for rural (vs urban) residence on current smoking decreased from 1.17 (95% CI: 1.03–1.32) to 1.14 (95% CI: 1.01–1.29) to 1.08 (95% CI: 0.96–1.21) across the stepwise models. Lower cigarette risk perceptions confounded the rural-current smoking association and was an independent risk factor for smoking (adjusted RR, ARR=2.15; 95% CI: 1.94– 2.18). In sensitivity analyses, believing that cigarettes are very or extremely (vs somewhat, slightly, or not at all) harmful to health and agreeing (vs not agreeing) that secondhand smoke causes lung disease in people who do not smoke, confounded the rural-current smoking association whereas beliefs about smoking causing lung cancer or lung disease in people who smoke did not. Conclusions Lower cigarette risk perceptions among rural residents confounded the positive association between rural residence and current smoking. Results from sensitivity analyses highlight potential targets for communication campaigns aimed at promoting more accurate perceptions of the harmful health consequences of cigarette smoking.

INTRODUCTION Cigarette smoking and smoking-related lung disease are more common in rural (vs urban) areas of the United States (US). This study examined relationships between geographical location, cigarette risk perceptions, and current smoking among older adults who are at greatest risk of developing smoking-related lung disease. METHODS The study was a secondary data analysis of 12126 respondents aged ≥40 years from Wave 5 of the Population Assessment of Tobacco and Health Study. Weighted descriptive statistics and Poisson regressions assessed current smoking (vs never or former) as a function of geographical location in a stepwise fashion, first unadjusted, then adjusting for sociodemographic characteristics, and finally for both sociodemographic characteristics and cigarette risk perceptions (4-item scale), in three separate models. Sensitivity analyses examined whether individual risk perceptions items had a greater impact on the association between geographical location and current smoking. RESULTS Current smoking was more common among rural (20.6%) than urban (17.6%) residents. The risk ratio (RR) for rural (vs urban) residence on current smoking decreased from 1.17 (95% CI: 1.03-1.32) to 1.14 (95% CI: 1.01-1.29) to 1.08 (95% CI: 0.96-1.21) across the stepwise models. Lower cigarette risk perceptions confounded the rural-current smoking association and was an independent risk factor for smoking (adjusted RR, ARR=2.15; 95% CI: 1.94-2.18). In sensitivity analyses, believing that cigarettes are very or extremely (vs somewhat, slightly, or not at all) harmful to health and agreeing (vs not agreeing) that secondhand smoke causes lung disease in people who do not smoke, confounded the rural-current smoking association whereas beliefs about smoking causing lung cancer or lung disease in people who smoke did not. CONCLUSIONS Lower cigarette risk perceptions among rural residents confounded the positive association between rural residence and current smoking. Results from sensitivity analyses highlight potential targets for communication campaigns aimed at promoting more accurate perceptions of the harmful health consequences of cigarette smoking. [ABSTRACT FROM AUTHOR]

This study investigates the effect of e-cigarette-related harm and addiction perceptions on e-cigarette initiation among US tobacco-naïve adolescents. This is a longitudinal study. Using data from five waves (2013–2019) of the Population Assessment of Tobacco and Health Study, we created a longitudinal data set for 2775 youth aged 12–17 years who had no prior use of tobacco products at Wave 1. E-cigarette initiation was defined as transitioning from non-use at Wave 1 to ever use in subsequent waves. Kaplan–Meier survival and Cox proportional hazard regression models were used to assess the impact of harm and addiction perceptions on e-cigarette initiation. Our analytic sample comprised 63.1% of youth who had never used tobacco products at Wave 1 and consequently initiated e-cigarette use in subsequent waves. Over time, fewer individuals perceived e-cigarettes as harmless (14.1%–2.1%), whereas more perceived them as likely to cause addiction (53.7%–76.6%). Compared with perceiving e-cigarettes as a lot of harm, those perceiving some harm (adjusted hazard ratio [aHR] = 1.30, 95% confidence interval [CI]: 1.12–1.52), little harm (aHR = 1.42, 95% CI: 1.20–1.68), or no harm (aHR = 2.09, 95% CI: 1.64–2.65) were more likely to initiate e-cigarette use. Demographic factors for initiation included being Black or Hispanic ethnicity (vs White), younger age (12–14 vs15–17 years), and receiving over $20 per week (vs $0) in pocket money, with P -values <0.05. However, in adjusted results, addiction perceptions did not significantly impact e-cigarette initiation (P -values >0.05). Among youth without prior tobacco/nicotine use, perceiving e-cigarettes as having low harm significantly predicted initiation over time. Effective prevention strategies, including targeted risk communication interventions, are essential for discouraging e-cigarette use among youth. [ABSTRACT FROM AUTHOR]

Previous studies showed that when reading a scenario depicting a harmless moral violation in the domain of purity, people nevertheless implicitly infer that harm was involved. In this study, we assessed whether this "implicit completion" process found in the perception of immoral actions is also present in people with autism spectrum disorder. In two experiments, we found an implicit activation of harm representations in response to all kinds of moral violations in neurotypical adults as well as in adults with autism. These results suggested that the perception of moral violations is relatively preserved in people with autism. [ABSTRACT FROM AUTHOR]

Background: Research is needed to identify the determinants of motivation to quit smoking among non-Hispanic Black (NHB) adults who smoke menthol cigarettes and reside in communities covered by menthol cigarette bans. Objectives: This study examined the associations between motivation to quit smoking and a range of individual-level predictors, including measures of demographics, harm/risk perception of menthol cigarettes, and awareness of a ban on menthol cigarettes in Los Angeles County unincorporated communities. Self-identified NHB adults who currently smoke menthol cigarettes (N=50; M=47.2 years; SD=13.7; 46% female) were recruited in Los Angeles County unincorporated communities. Participants completed an interviewer-administered cross-sectional survey between January to September 2021. Results: Participants (74%) reported an annual household income of less than $25,000. Participants' mean age at cigarette initiation was 15.7 years old (SD=5.68). Most (88%) were aware of the ordinance banning menthol cigarette sales. Employing multivariable linear regression analysis, harm/risk perception of menthol cigarettes (B=14.69, p<0.01) and awareness of the local menthol ban (B=26.18, p<0.05) were found to be independently associated with motivation to quit smoking. Conclusions: Findings from this community-based sample suggest that among NHB adults who smoke menthol cigarettes, motivation to quit smoking is influenced by their perception of menthol cigarettes as harmful and awareness of local policy banning the sale of menthol cigarettes. Findings underscore the need for community-centered and culturally grounded interventions to facilitate quitting among NHB adults who smoke in order for communities covered by menthol bans to achieve health equity in reducing preventable racial inequities due to menthol cigarettes. [ABSTRACT FROM AUTHOR]

Oral nicotine pouches may appeal to young adult current nicotine/tobacco users interested in alternative forms of nicotine that lack pulmonary exposure, but may also appeal to young adult non-users of nicotine/tobacco products. We used data from a 2020 remote digital survey of an ongoing cohort study of young adults from Southern California (aged 19-23) to examine differences in pouch perceptions and use willingness across nicotine/tobacco use statuses. Participants who had never used nicotine pouches (N = 1167) viewed text/imagery from mass-marketed pouch packaging and advertising, then completed measures of willingness to use nicotine pouches, pouch harm perceptions, and hypothetical choice of cigarettes or e-cigarettes over pouches. Willingness to use pouches was significantly higher among non-combustible only (33.8%), combustible only (29.3%), and dual (43.9%) users than non-users (14.7%). Overall, 49.1% of participants were uncertain whether pouches were less harmful than cigarettes and 52.4% were uncertain whether pouches were less harmful than e-cigarettes. Relative harm perceptions did not significantly differ by tobacco use status. Those using non-combustible products (either alone or as part of dual use with combustible tobacco) had greater odds than non-users of reporting that they would use e-cigarettes over nicotine pouches. By contrast, all tobacco product user groups reported greater odds than non-users that they would use cigarettes over pouches. In sum, a sizable minority of young adults might be willing to try using nicotine pouches, but most are uncertain about the relative harm of pouches.

Objective: Synthetic nicotine (SN) e-cigarettes emerged on the market as an alternative to tobacco-derived nicotine (TDN) vaping products. It is critical to understand the harm perceptions, purchase, and use of SN vs. TDN e-cigarettes. Methods: From November 2021 to February 2023, we conducted intercept interviews with 263 adult customers at 37 vape shops in Southern California. Self-reported use and harm perceptions towards SN vs TDN e-cigarettes were examined. A qualitative analysis of researcher-obtained photographs of vaping items just purchased by customer participants was conducted. Results: Past 30-day SN e-cigarette use was reported by 44 (16.7 %) customers. Past 30-day SN e-cigarette users vs. non-users reported vaping on more days in the past month (29.3 vs. 26.1 days, p = 0.02). Overall, 23.8 % of participants perceived SN e-cigarettes as less harmful than TDN ones; never-smoking vapers and dual users perceived SN e-cigarettes as less harmful than salt-based TDN e-cigarettes. Among 44 customers who purchased SN products (verified through qualitative analysis of photographs), only 13 (29.6 %) self-reported using SN products in the past month, while 5 (11.4 %) indicated they were not aware of the existence of SN products. Most SN vaping products (71.4 %) displayed a modified “tobacco-free” warning label. Conclusions: Misperceptions about SN e-cigarettes were documented in this study, including the perception that SN is either less or more harmful than TDN. Further, some customers may be unknowingly purchasing and using SN e-cigarettes. Regulating “tobacco-free nicotine“ terminology in SN vaping products marketing is suggested. SN product labeling should not imply that SN is safe/safer than TDN.

Mediation analysis has been widely applied to explain why and assess the extent to which an exposure or treatment has an impact on the outcome in health psychology studies. Identifying a mediator or assessing the impact of a mediator has been the focus of many scientific investigations. This tutorial aims to introduce causal mediation analysis with binary exposure, mediator, and outcome variables, with a focus on the resampling and weighting methods, under the potential outcomes framework for estimating natural direct and indirect effects. We emphasize the importance of the temporal order of the study variables and the elimination of confounding. We define the causal effects in a hypothesized causal mediation chain in the context of one exposure, one mediator, and one outcome variable, all of which are binary variables. Two commonly used and actively maintained R packages, mediation and medflex, were used to analyze a motivating example. R code examples for implementing these methods are provided. [ABSTRACT FROM AUTHOR]

Concurrent electronic cigarette (e-cigarette) and cigarette use has been rising among college students. Thus, we investigated the following aims in a sample of 533 Korean college students: (a) characteristics of cigarette consumption in three e-cigarette use groups, (b) perceived relative harm of e-cigarettes and the greatest reason for e-cigarette use (EU), and (c) factors associated with EU among lifetime cigarette smokers. We conducted descriptive statistics, analysis of variance, Fisher's exact test, and multinomial logistic regression. EU was significantly associated with lifetime and past 30-day cigarette smoking and the number of cigarette-smoking days and cigarettes smoked. Most e-cigarette users considered e-cigarettes as less harmful. Main reasons for EU were no smell, lower harm, and feasibility to use in non-smoking areas. Finally, EU among lifetime cigarette smokers was strongly associated with male sex, younger age, and greater numbers of cigarette-smoking days. Anti-smoking education and anti-smoking regulations should be systematically implemented on campus. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the trend of harm perception for e-cigarettes and the trend of the association between harm perception for e-cigarettes and for cigarettes among US youth from 2014 to 2019. Design, setting and subjects: The National Youth Tobacco Survey is an annual, cross-sectional, school-based survey done among youth selected using three-stage probability sampling. Analysis: Data were drawn from the 2014 to 2019 Surveys. A Multinomial logistic regression model was used to assess the association between harm perception for e-cigarettes and harm perception for cigarettes for each year. Results: The percentage of youth who perceived e-cigarettes as harmless decreased from 2014 to 2019 (17.2% to 5.8%). From 2015 to 2018, the percentage of smokers who perceived e-cigarettes as a little harmful increased (33.6% to 41.2%). The positive association between harm perception for e-cigarettes and harm perception for cigarettes became stronger with time. In 2014, the odds of perceiving e-cigarettes as harmless relative to very harmful were 19.55 times greater for youth who perceived cigarettes as harmless, compared to those who perceived cigarettes as very harmful (OR = 19.55; 95% CI: 14.19–26.94). These odds increased to 77.65 times in 2019 (OR = 77.65; 95% CI: 41.48–107.85). Conclusion: This study suggests a stronger relationship between perceived harm of cigarettes and e-cigarettes with time. Interventions to prevent smoking have the potential to change e-cigarette use. [ABSTRACT FROM AUTHOR]

Objectives: The use of alternative nicotine products by middle and high school students is a growing concern due to industry marketing techniques, availability, and popularity of new products, and ambiguous nicotine concentrations. The 2021 National Youth Tobacco Survey (NYTS) provides information about the frequency, and characteristics of middle, and high school students who have used nicotine pouches. Methods: The National Youth Tobacco Surveys provide important information about the frequency of use of tobacco and alternative nicotine products by a representative sample of students in schools in the United States. The 2021 survey included questions about the use of nicotine pouches/dissolvable tobacco products. The results from the survey were analysis using descriptive statistics, and logistic regression to model the association between the use of these alternative nicotine products, and the use of electronic cigarettes or the use of conventional cigarettes. Results: A total of 20 413 students participated in the survey year 2021; 17 842 were included in the final data analysis. Their ages ranged from 9 to 18+. Identified risk factors for the use of alternative nicotine products included race, and age. The adjusted odds ratio (OR) was lower in non-Hispanic Black and Hispanic students, as compared to non-Hispanic White students. Older students had a substantially higher risk of using nicotine/dissolvable tobacco products, specifically, compared to students less than or equal to 13 years old. The OR increased 174% (OR: 2.74; 1.70-4.41) in 17-year-old students. The perception of harm associated with electronic cigarettes increased the likelihood of using alternative nicotine products. Students who did not smoke cigarettes (OR: 0.39; 0.27-0.56) or did not smoke electronic cigarettes (OR: 0.20; 0.18-0.40) had significantly lower OR for using alternative nicotine products. Conclusions: The 2021 National Youth Tobacco Survey indicates that a relatively small percentage of middle school and high school student have used nicotine pouches. However, with the increase in new, alternative tobacco products, understanding adolescent use in comparison to other tobacco products is an important trend to monitor. [ABSTRACT FROM AUTHOR]

Abstract Introduction The 21st century was marked by a dramatic increase in adolescent e-cigarette use in the United States (US). The popularity of non-traditional flavor types, including fruit and pastry, is thought to contribute toward growing product use nationally, leading to a variety of federal and state regulations limiting the use of non-traditional flavors in the US. The relationship between flavor type and increased adolescent use suggests a possible link between flavor use and addiction and harm perception. This study assessed if the flavor type used when initiating e-cigarette use predicted addiction and harm perceptions. Methods The study utilized data from the multi-wave youth Population Assessment of Tobacco Health Study. It explored the impact initiating e-cigarette use with traditional versus non-traditional flavor types among cigarette users on the outcome variables: e-cigarette addiction and harm perception. Both e-cigarette addiction and harm perception were measured using self-report, Likert scale questionnaires. Descriptive statistics characterized the study variables and linear regression analyses performed to test whether flavor initiation type is associated with addiction and harm perception. Results The study sample consisted of 1,043 youth (weighted N = 1,873,617) aged 12 to 17 years who reported at least one instance of e-cigarette use. After adjusting for age, age of onset, sex, race and annual household income there was no statistically significant difference in addiction levels between those initiating with traditional versus non-traditional flavors (p = 0.294). Similarly, traditional versus non-traditional flavor initiation did not show a statistically significant difference in adolescent e-cigarette harm perceptions (p = 0.601). Conclusions Traditionally flavored e-cigarette initiation produces similar risk for addiction and harm perceptions as non-traditionally flavored initiation. These findings suggest that banning non-traditional flavors alone may be ineffective in curbing e-cigarette addiction and harm perception. Additional research is needed to better understand which e-cigarette product characteristics and behaviors may be associated with greater addiction and reduced harm perceptions.

The aim of this study is to examine US youths' harm perceptions toward nondaily use of e-cigarettes, cigarettes, cigars, smokeless tobacco, and hookahs. The nationally representative, cross-sectional National Youth Tobacco Survey annually assessed the following: "How much do you think people harm themselves when they [use tobacco products] some days but not every day?" Weighted estimates for 2020 were generated overall (grades 6–12) and by select demographics. Multivariable regression examined linear and quadratic changes during 2016–2020 (excluding cigars). In 2020, the prevalence of middle and high school students reporting "no" or "little" harm (vs. "some" or "a lot") was 20.1% for e-cigarettes, 17.4% for hookahs, 14.6% for cigars, 13.5% for smokeless tobacco, and 11.0% for cigarettes. During 2016–2020, perceptions of "no" or "little" harm decreased for e-cigarettes, increased for cigarettes and smokeless tobacco, and exhibited nonlinear changes for hookahs. Most youth are aware of tobacco product harms, but opportunities exist to educate youth about the harms of nondaily tobacco product use. [ABSTRACT FROM AUTHOR]

Introduction Tobacco companies have introduced heated tobacco products (HTPs), such as IQOS, which may compete with e-cigarettes among smokers interested in switching to potentially reduced-risk products. Non-smokers may also start using IQOS if they believe this product is less harmful than other nicotine products. Smokers’ and non-smokers’ decisions may be driven by relative harm perceptions of emerging nicotine products. We aimed to examine relative harm perceptions between IQOS, e-cigarettes, and cigarettes, among nicotine product users and non-users. Material and Methods We conducted a web survey with Canadian respondents (aged ≥20 years; n=268) in September–October 2018. Perceptions about relative harm between IQOS (available for sale since 2017 and subject to the same comprehensive marketing restrictions as cigarettes in Canada), e-cigarettes, and cigarettes, were assessed among non-users (n=79), exclusive smokers (n=78), exclusive e-cigarette users (n=32), and dual users (n=79). Multiple logistic regression explored the association between relative harm perceptions and nicotine-use status, adjusting for sociodemographic variables. Results Over half of respondents perceived IQOS as equally or more harmful than e-cigarettes (53.7%), while almost a quarter either reported IQOS as less harmful than e-cigarettes or were uncertain (22.7% and 23.5%, respectively). Two-thirds of respondents (65.7%) perceived e-cigarettes as less harmful than cigarettes, yet only half (48.1%) perceived IQOS as less harmful than cigarettes. Both exclusive and dual e-cigarette users, but not exclusive smokers, had higher odds of perceiving IQOS as more harmful than e-cigarettes and less harmful than cigarettes compared to non-users. Conclusions Most nicotine users and non-users perceive differential health risk across IQOS, e-cigarettes, and cigarettes. Although e-cigarettes are generally viewed as less harmful than cigarettes, the perceived harm of IQOS was unclear.

Despite well-documented disparities disadvantaging women (e.g. discrepancies between men and women in salaries and leadership roles), we argue that there are contexts in which disparities disadvantage men. We review the literature suggesting harm to women is perceived as more severe and unacceptable than identical harm to men, a bias potentially rooted in evolutionary, base rate, stereotype-based and cultural shift explanations. We explore how these biases manifest in protective responses toward women and harsher judgements toward men, particularly in contexts of victimization and perpetration. Our review aims to complement the existing literature on gender biases by presenting a balanced view that acknowledges men and women face unique challenges. By understanding these biases, we hope to foster a more equitable discourse on gender and harm, encouraging empathy and validation of suffering irrespective of gender. This holistic approach aims to de-escalate gender-based conflicts and promote effective interventions for both men and women.

Although overall smoking prevalence in Minnesota has declined, the proportion of current smokers who smoke menthol cigarettes has increased. While studies have examined associations between smokers’ perceived risks of smoking and quitting, similar studies on menthol smoking are lacking. This study examined whether perceived harm of menthol cigarettes was associated with menthol smokers’ quitting behaviors.Data from the 2018 Minnesota Adult Tobacco Survey were examined. Respondents were categorized as current menthol smokers (n = 200), current nonmenthol smokers (n = 527), or nonsmokers (n = 5324). All were asked four questions to assess their perceptions of menthol cigarettes’ harm compared to nonmenthols. Sum scores were calculated (range 0–4); higher scores indicated perceptions of similar or greater harm. Data on menthol smokers’ quitting behaviors were analyzed to identify associations between sum scores and quitting behavior. Data were analyzed using Wilcoxon Rank Sum tests and Spearman Rank Correlation tests. Additional analyses examined whether gender, age, race/ethnicity, education or income moderated the association between sum scores and past 12-month quit attempts.Menthol smokers were less likely to answer the harm perception questions correctly than nonmenthol smokers. Among menthol smokers, perceived harm of menthol cigarettes was positively associated with past 12–month quit attempts (p = 0.006), use of counseling/behavioral support (p = 0.012), and number of quit attempts (p = 0.004). No demographic characteristics moderated the association between sum scores and past 12-month quit attempts.Findings suggest that efforts to increase menthol smokers’ perceptions of menthol cigarettes’ harm may potentially increase quitting behaviors. Understanding this association can inform interventions to increase quit attempts.

Background: National estimates of electronic vaping product (EVP) use exist, but little is known about young adult EVP users who interact with the healthcare setting. Methods: Cross-sectional survey of 18–25 year olds receiving care in our ambulatory medical practice. Population differences were evaluated with the chi square test reporting unadjusted odds ratios (ORs). Results: Response rate was 16.6% (n = 1,017/6,119). The prevalence of ever EVP use was 46.0% of whom 13.9% used every day. Each additional day of alcohol use (past 30 days) was associated with increased odds of being an EVP user (OR = 1.06, 95% CI 1.02–1.09), and cannabis use (past 30 days) was associated with a higher odds of being an EVP user compared to non-cannabis users (OR = 40.0, 95% CI 17.4 − 111.8). Observing a biological parent (OR = 2.89, 95% CI 1.98–4.24), step parent (OR = 2.03, 95% CI 1.02–4.19) and full sibling (OR = 2.31, 95% CI 1.78–3.00) using inhaled substances (past 30 days) was associated with increased odds of being an ever EVP user. Ever EVP users had lower odds than never users to report that EVPs with nicotine are "a little" or "a lot" more harmful than smoking "regular" tobacco cigarettes (OR = 0.53, 95% CI 0.37 − 0.76). Conclusion: Our survey is limited by a low response rate but confirms observed associations between EVP use and substance use and social influences. Our data also suggest that professionals should regularly screen for EVP use among young people, especially those with exposure to family members who used inhaled substances. [ABSTRACT FROM AUTHOR]

Objective: Describe workplace vaping, prevalence of observed use. attitudes, and perceptions among US adults. Methods: Employees of companies with more than 150 employees, drawn from an opt-in national online panel (N= 1607), ages 18 to 65, completed an online survey in November 2019. Results: Majority (61.6%) observed coworkers vaping at work and 19.1% reported vaping at work themselves. Participants perceived workplace vaping as moderately harmful (M= 1.9 out of 3), 63.2% were bothered by workplace vaping and 52.1% thought it decreased workplace productivity among non-users. Multiple regression models found workplace vaping prevalence varied by industry and participant characteristics, and attitudes about it varied by tobacco use status. Conclusions: Workplace vaping and vaping exposure is common in US workplaces. Employees, particularly non- users. hold generally negative perceptions of workplace vaping. Comprehensive policies to prevent workplace vaping are needed to protect workers. [ABSTRACT FROM AUTHOR]

Background: Drug policies aimed at youth often adopt "scare tactics" approaches, which highlight harms of substances to dissuade youth from using them. However, the success of deterrent approaches remains widely debated, and some scholars have cautioned that these approaches may do more harm than good. Methods: Drawing on a sample of adolescents from the 2016 Monitoring the Future study, we investigated the influence of perceived drug harmfulness alongside several other risk factors for substance use. Logistic regression models assessed the relative influence of perceived harmfulness, access, peer use, and disapproval on youths' past year use of marijuana, crack cocaine, and powder cocaine. Results: Perceived drug harmfulness was no longer associated with the use of marijuana and crack cocaine when considering other risk factors. Perceptions of harmfulness were only related to powder cocaine use. In addition, the impact of peer use, access, and disapproving attitudes varied by substance examined. Conclusions: Regarding marijuana and crack cocaine, we find evidence against the deterrence perspective and show that focusing solely on the harms of using a substance may not be an effective policy approach in reducing the use of these substances among adolescents. Programs may also perhaps increase their efficacy by adopting substance-specific approaches. [ABSTRACT FROM AUTHOR]

What causes people to see their political attitudes in a moral light? One answer is that attitude moralization results from associating one's attitude stance with feelings of disgust. To test the possibility that disgust moralizes, the current study used a high-powered preregistered design looking at within-person change in moral conviction paired with an experimental manipulation of disgust or anger (versus control). Results from the preregistered analyses found that we successfully induced anger but not disgust; however, our manipulation had no effect on moral conviction. Additional exploratory analyses investigating whether emotion and harm predicted increases in moral conviction over time found that neither disgust, anger, nor sadness had an effect on moralization, whereas perceptions of harm did predict moralization. Our findings are discussed in terms of their implications for current theory and research into attitude moralization. [ABSTRACT FROM AUTHOR]

• 60% of youth reported exposure to e-cigarette advertisements through at least one channel. • E-cigarette advertisements had a long-term indirect impact on youth e-cigarette use. • There was no enduring direct influence of e-cigarette advertisements. • Adolescents with fewer internalizing problems were more vulnerable to advertising influence. • Adolescents with higher levels of internalizing problems perceived e-cigarettes as less harmful. Prior research indicates a direct, short-term effect of e-cigarette advertising on e-cigarette use among youth. This study seeks to investigate the long-term effects of e-cigarette advertisements and disparities in exposure among adolescents with different levels of internalizing problems. Panel data of the Population Assessment of Tobacco and Health (PATH) Study Waves 3–5 (2015–2019) were analyzed. Youth aged 12–17 who were non-e-cigarette users at the time of Wave 3 were included (n = 4,678). A moderated mediation model was employed to examine the mediating role of perceived harm of e-cigarettes and the moderating effect of internalizing problems. Exposure to e-cigarette advertisements in Wave 3 predicted lower harm perception of e-cigarette in Wave 4 (bp = -0.055, p <.01), leading to more e-cigarette use in Wave 5 (bp = -0.042, p <.001). While e-cigarette advertisements exhibited a lasting indirect effect (bp = 0.002, p <.05), there was no long-term direct effect (bp = 0.017, p >.05) on youth e-cigarette use. Furthermore, a moderating effect of internalizing problems was observed (bp = 0.107, p <.05). E-cigarette advertisements can exert a lasting influence indirectly by diminishing harm perception, particularly among those with lower internalizing problems. Adolescents with higher internalizing problems exhibit lower susceptibility to advertisement influence, yet their perceived harm of e-cigarettes is notably lower than their peers with fewer internalizing problems. These disparities underscore the need for tailored prevention strategies: implementing anti-e-cigarette education programs for adolescents with low internalizing problems and providing mental health care for those facing internalizing challenges. Regulatory measures targeting e-cigarette advertising are also crucial. [ABSTRACT FROM AUTHOR]

BACKGROUND: Electronic nicotine-delivery systems have been increasing in prevalence among young adults. Although these devices are marketed to aid in quit smoking, young adults who do not smoke traditional cigarettes are using these devices. This study explored associations between individuals' quit type (ie, no plans to quit, plans to quit, or quit > 6 months ago) and perceived health status, perception of harm compared to cigarettes, perception of secondhand vapor harm, and reasons for first use. METHODS: We utilized a cross-sectional study design using a 33-item electronic survey questionnaire. The total sample size was 2,792. Out of these the ENDS users were 1,217. The survey was distributed to university students in 5 areas in 3 countries: the United States (ie, Florida, Alabama, and Illinois), Germany (ie, Hamburg) and South Africa (ie, Potchefstroom). RESULTS: Quantitative data analysis indicated that, regardless of quit status, there was a general lack of knowledge regarding secondhand vapor effects. Additionally, young adults are utilizing these products primarily due to peer influence and stress relief. Harm perception may factor into quit attempts using electronic nicotine-delivery systems. CONCLUSIONS: Education provided by respiratory therapists (and to respiratory therapy students) would be valuable as they inform patients and communities of the scholarly literature on vaping devices. [ABSTRACT FROM AUTHOR]

Background and aims: People's perceptions of the harmfulness of e‐cigarettes, compared with cigarettes, may influence their product use decisions. We tested if perceiving e‐cigarettes as less harmful than cigarettes predicted whether cigarette and e‐cigarette dual users switched their product use status 1 year later, becoming exclusive e‐cigarette users, exclusive cigarette smokers, or non‐users of both product types. Design Longitudinal analyses of waves 2 (2014–15) and 3 (2015–16) of the prospective, national Population Assessment of Tobacco and Health (PATH) Study. Setting: United States. Participants: Adults who reported using both cigarettes and e‐cigarettes within the past 30 days at wave 2 reported their perceptions of e‐cigarette harm at wave 2, and reported whether they used cigarettes and e‐cigarettes within the past 30 days at wave 3 (n = 2211). Measurements The key predictor was wave 2 perceptions of e‐cigarette harm compared with cigarettes ('less harmful,' 'about the same', 'more harmful' or 'don't know'). The key outcome was wave 3 past 30‐day use of e‐cigarettes and cigarettes, classified into four categories: exclusive e‐cigarette use (i.e. use of e‐cigarettes but not cigarettes), exclusive cigarette smoking (i.e. use of cigarettes but not e‐cigarettes), dual use of both product types and non‐use of both product types. Findings At wave 2, 59.4% of dual users perceived e‐cigarettes as less harmful than cigarettes [95% confidence interval (CI) = 56.9, 61.9]. Compared with those with other perceptions of e‐cigarette harm, dual users who perceived e‐cigarettes as less harmful than cigarettes were more likely to become exclusive e‐cigarette users 1 year later [7.5 versus 2.7%; adjusted odds ratio (aOR) = 2.9, 95% CI = 1.7–4.8], more likely to remain dual users (39.6 versus 29.9%; aOR = 1.5, 95% CI = 1.2–1.8), less likely to become exclusive cigarette smokers (44.8 versus 59.4%; aOR = 0.6, 95% CI = 0.5–0.7) and similarly likely to become non‐users of both product types (8.2 versus 8.0%; aOR = 1.1, 95% CI = 0.7–1.7). Conclusions: US adult dual users of e‐cigarettes and cigarettes who perceive e‐cigarettes as less harmful than cigarettes appear to be more likely to switch to exclusive e‐cigarette use, more likely to remain dual users and less likely to switch to exclusive cigarette use 1 year later than dual users with other perceptions of e‐cigarette harm. [ABSTRACT FROM AUTHOR]

Introduction and Aims: Despite regulatory barriers for accessing nicotine liquid, use of nicotine vaping products (NVPs) has increased rapidly in Australia. Legal use of NVPs to aid smoking cessation requires a prescription, and pharmacies report receiving enquiries about the use of and access to NVPs. In this study, we assessed vaping product use, harm perception and policy support among community pharmacy customers.Design and Methods: A cross-sectional survey was conducted among customers (n = 470) from a large community pharmacy chain in Brisbane, Australia. Multivariable logistic regression was used to examine perception of NVPs as less harmful than combustible cigarettes and regulatory recommendations in relation to demographics, smoking status and NVP use.Results: Almost one-third of the sample (31%) had either tried NVPs in the past (16%) or were current vapers (15%), the majority of them being current smokers (67%) who are trying to quit (31%) or substitute smoking (41%). Vapers primarily depended on family/friends as a source of information (76%). Current smokers and vapers were more likely to perceive NVPs as less harmful than cigarettes than non-smokers and non-vapers. Perceiving NVPs as safer than cigarettes was correlated with a recommendation to regulate as a tobacco product.Discussion and Conclusions: There was widespread misperception about relative risk of nicotine-containing products, with 37% of respondents perceiving nicotine-containing NVPs to be as harmful as combustible cigarettes. Community pharmacies represent an ideal setting for educating smokers about smoking and vaping. Thus, pharmacy staff needs educational support to ensure that they are equipped to provide current evidence-based information to customers. [ABSTRACT FROM AUTHOR]

Objectives: The US Food and Drug Administration (FDA) and Santa Fe Natural Tobacco Company reached an agreement in January 2017 to remove "additive-free" and "natural" from Natural American Spirit (NAS) marketing because these terms led consumers to perceive reduced harm inaccurately. This study sought to update previous research by examining brand marketing following these restrictions. Methods: A content analysis was conducted on 244 ads from 2015-2018. Two coders coded text descriptors, references, and imagery that implied or referenced natural or environmental qualities, and American Indian symbols. Results: From 2015-2018, NAS used descriptors that could imply a natural product, including "organic," "tobacco and water," and "whole leaf." Imagery included natural images such as plants (79.5%), farms (60.7%), or wood (85.2%). Most ads contained American Indian imagery (90.6%). There were 20 apparent violations of the FDA agreement restricting "natural" and "additive-free" in the 3 months after it went into effect (September-November 2017). Conclusions: Although "natural" and "additivefree" were eliminated from marketing in 2017, NAS relied on a variety of other descriptors and images that could imply a natural product. Research should examine whether these tactics similarly convey inaccurate reduced harm to consumers. [ABSTRACT FROM AUTHOR]

Background and aims: E‐cigarettes (EC) and nicotine replacement therapy (NRT) are less harmful than smoking, but misperceptions of relative harm are common. Aims were to (1) assess nicotine knowledge and perceptions of: harm of EC and NRT relative to smoking, addictiveness of EC relative to smoking, and change in harm to user if smoking replaced with EC; (2) define associations of these perceptions with respondent characteristics including nicotine knowledge; and (3) explore perceived main harms of EC and whether these differ by vaping status. Design Analyses were: (1) frequencies; (2) logistic regressions of perceptions of relative harm, addictiveness and change in harm onto demographics, smoking and vaping status and nicotine knowledge (attributing cancer or health risks of smoking to nicotine); and (3) frequencies and χ2 statistics. Setting and participants: Participants were smokers and recent ex‐smokers from one wave (September 2017) of a longitudinal online survey in the United Kingdom (n = 1720). Measurements Demographics included gender, age, smoking status, vaping status and income. Survey questions collected data on nicotine knowledge and harm perceptions of different products; the relative harm perceptions of NRT, EC and tobacco cigarettes; and perceived main harms of EC. Findings Relative to smoking, 57.3% perceived EC and 63.4% NRT to be less harmful; 25.4% perceived EC to be less addictive; and 32.2% thought replacing smoking with EC reduced health harms a great deal. Participants were less likely to endorse these beliefs if they had never vaped, and participants who had inaccurate nicotine knowledge were less likely to endorse all these beliefs apart from the addictiveness of EC. The main concerns about EC were a lack of research (48.3%), regulation or quality control (37.8%) and harmfulness of chemicals (41.6%). Conclusions: Large proportions of UK smokers and ex‐smokers overestimate the relative harmfulness of e‐cigarettes and nicotine replacement therapy compared with smoking; misattributing smoking harms to nicotine is associated with increased misperceptions. [ABSTRACT FROM AUTHOR]

Tobacco kills half of its users, and despite the achievement of public health policies in plummeting cigarette smoking worldwide, waterpipe smoking (WPS) is emerging to sustain tobacco consumption. Hence, this study sought to determine the prevalence, harm perception, correlates of favourable harm perception and predictors of WPS among undergraduate students in University of Ibadan. A cross sectional descriptive study was conducted among 390 undergraduate students residing in the halls at the University of Ibadan. Data were obtained using a semi-structured questionnaire and analysed with SPSS 21. A Likert scale was used to determine the harm perception of WPS by current smokers. A Bi-variate analysis was used to test for associations and correlates of favourable harm perception while logistic regression was carried out to determine predictors of WPS. The study revealed that mean age of initiation of WPS was 18.5 ± 2.7years, 3.9% were current users. 33% of current WP users had favourable harm perception. Health warnings on shisha smoking packages and considering shisha use as smoking were significant correlates of favourable harm perception. Ever cigarette smoking [p=0.013; 95% CI; 1.7-84.4], smoking of other products aside cigarette [p=0.012; 95% CI; 1.7-94.0], having all close friends as smokers [p=0.016; 95% CI; 3.3-129.4], having divorced parents [p=0.002; 95% CI; 3.5-216.0] and shisha smoking among siblings [p=0.001; 95% CI; 2.0-124.1] were predictors of current WPS. There is less awareness on WPS health consequences among the University’s undergraduate students. Hence, advocacy strategies on the harms of WPS and specific laws regulating WPS should be established. Funding This study was self financed.

Introduction Waterpipe tobacco smoking (WTS) continues to be very common in the Eastern Mediterranean Region (EMR), partially because of cultural acceptance but also because of misconceptions of its harm. This paper aimed to describe the beliefs towards waterpipe harm of university students who smoked waterpipe in five EMR countries. Methods This study was conducted in 2016 across five EMR countries: Egypt, Jordan, Occupied Palestinian Territories, Oman and United Arab Emirates (UAE). Participants were recruited from among university students in each country. Students’ characteristics, smoking behavior, flavor preference and knowledge of WTS harm were collected using an internet-based survey. Participants were included if they were ever waterpipe tobacco smokers and between 18 and 29 years of age. Bivariate analyses assessed variations in student-perceived WTS harm across the countries. Linear regression analysis was used to assess WTS perceived harm differences between students in the different countries. Results A total of 2 544 university students participated from the five countries. Among ever smoking students, 66% reported WTS in the past 30 days, with the highest proportions (40%) from Occupied Palestinian Territories (OPT) and (41%) Jordan. Dual smoking of waterpipe and cigarettes was highest among students from Egypt. Most participants from the five countries had high level of perceived harm related to WTS during pregnancy. Less than 50% of the students believed that WTS could lead to the death of the smoker, can be harmful for non-smokers and have an addictive effect. Female students, those older than 22 years, and those who didn’t smoke waterpipe in the last 30 days significantly had a higher level of WTS perceived harm. Participating students believed that cigarettes are more addictive and contain more nicotine compared to waterpipe. Conclusions Misperceptions of waterpipe harm are common among university students in the five EMR countries. Immediate public health action is needed, including enforcement of waterpipe tobacco control regulations along with awareness campaigns.

Perceptions of harm and addictiveness are associated with smoking combusted cigarettes, but these factors have not been fully explored for e-cigarettes. Specifically, little is known about the perceived harm and addictiveness of e-cigarettes, or whether information-seeking about e-cigarettes is related to trying e-cigarettes. We aimed to determine the relationship between (1) perceived e-cigarette harm and addictiveness and trying e-cigarettes; (2) nicotine perceptions and trying e-cigarettes; and (3) e-cigarette information-seeking, Internet use, and trying e-cigarettes. We used data from the nationally representative 2015 Health Information National Trends Survey-FDA (HINTS-FDA 2015). Weighted multivariable logistic regression models assessed independent associations between perceived e-cigarette harm, perceived e-cigarette addictiveness, nicotine perceptions, e-cigarette information-seeking, personal Internet use, and trying e-cigarettes, among 3195 adults. Compared to people who believed e-cigarettes were equally or more addictive than combusted cigarettes, those who believed e-cigarettes were less addictive had 2.49 times the odds of trying e-cigarettes (95% confidence interval [CI]: 1.30, 4.74). Perceived e-cigarette harm and nicotine perceptions were not associated with trying e-cigarettes. The positive association between e-cigarette addictiveness and trying e-cigarettes coupled with the lack of an association between nicotine perceptions and trying e-cigarettes suggests people do not fully understand that e-cigarettes contain nicotine and therefore could be addictive. People most frequently reported searching for information about potential health effects of e-cigarettes (37.9%), indicating that people are interested in learning about the potential impact of e-cigarette use on their health. People who searched for information about e-cigarettes had 10.23 higher odds of trying e-cigarettes (CI: 5.41, 19.33). [ABSTRACT FROM AUTHOR]

Background: E-cigarettes often contain nicotine without the most harmful constituents of tobacco smoke.Aims: This study aims to assess prevalence and correlates of accurately perceiving e-cigarettes as less harmful than cigarettes and that none or a small amount of the harm from smoking comes from nicotine.Methods: Cross-sectional survey of 2,103 11-18-year-olds in Great Britain in 2016. Prevalence of e-cigarette and nicotine harm perceptions were calculated. Logistic regressions assessed associations between accurate e-cigarette and nicotine harm perceptions and smoking, e-cigarette use, gender, age, region, social grade, family smoking, family e-cigarette use, smoking friends, public approval of smoking, and public approval of e-cigarettes. Associations between accurate e-cigarette and nicotine harm perceptions were also assessed.Results: Most (63.4%) accurate e-cigarette harm perceptions were higher among those aged 16+ (OR = 1.89 [95%CI = 1.45-2.47]), 14-15 (OR = 1.29 [1.00-1.65]), who tried/used an e-cigarette sometimes (OR = 1.51 [1.03-2.21]), with family e-cigarette use (OR = 2.11 [1.46-3.04]), who perceived public disapproval of smoking (OR = 2.11 [1.18-3.77]) and approval of e-cigarettes (OR = 2.44 [1.73-3.45]), and with accurate nicotine harm perceptions (OR = 2.05 [1.28-3.28]). Accurate nicotine harm perceptions were higher among those aged 16+ (OR = 2.60 [1.62-4.16]), from North England (OR = 1.87 [1.02-3.43]) and Wales/Scotland (OR = 2.61 [1.35-5.03]) vs. London, with family smoking (OR = 1.59 [1.05-2.42]), and with accurate e-cigarette harm perceptions (OR = 2.12 [1.32-3.41]).Conclusions: Many young people have inaccurate harm perceptions of e-cigarettes and nicotine. Accurate e-cigarette and nicotine harm perceptions were associated with one another. E-cigarette use was associated with accurate e-cigarette but not nicotine harm perceptions; smoking was not associated with either. [ABSTRACT FROM AUTHOR]

Introduction: Similar to cigarette smoking, consumption of cigars delivers nicotine and byproducts of tobacco combustion and elevates the risk of addiction, illness, and premature death. This study examined the relationship of affect, perceived relative harm, and LCC smoking behavior among U.S. adults.Methods: Data were from Tobacco Products and Risk Perceptions Survey conducted in 2015. The study included a probability based sample of 6051 adults (18+) drawn from an online research panel. A current LCC smoker was defined as having ever smoked LCCs and was currently smoking LCCs every day, somedays, or rarely. Participants were asked whether smoking LCCs was less harmful, had about the same level of harm, or was more harmful than smoking regular cigarettes. Feelings about LCCs were collected using word association technique. Descriptive and multinomial logistic regression analyses were conducted.Results: About 7% of the study participants were current LCC smokers. Adults with positive feelings had four-fold the adjusted odds to be current LCC smokers. Perceiving LCCs to be less harmful had 2.7 higher adjusted odds of being current LCC smokers.Conclusions: Compared to cigarettes, LCCs evoked more positive feelings among adults and these positive feelings were strongly associated with both perceiving LCCs as less harmful than cigarettes and with current LCC smoking. Cessation and prevention interventions would benefit from applying the principles of social marketing in which information is provided not only to inform consumers but also to evoke negative feelings and associations with LCC smoking. [ABSTRACT FROM AUTHOR]

Purpose We aimed to describe U.S. youth harm perceptions of intermittent tobacco use. Methods Using data from the 2016 National Youth Tobacco Survey of U.S. students (grades 6–12; N = 20,675), we examined prevalence and correlates of all respondents' perceived harm of using four different tobacco products on “some days but not every day.” Associations between current (past 30-day) use and harm perceptions were assessed using multivariable regression. Results Perceiving that intermittent use causes “no” or “little” harm was 9.7% for cigarettes, 12.0% for smokeless tobacco, 18.7% for hookah, and 37.5% for e-cigarettes. Compared with those who reported “a lot” of harm, youth with lower harm perceptions were more likely to report current use. Conclusions One in ten youth perceived intermittent cigarette smoking as causing “little” or “no” harm; this perception was higher among current users. Efforts to educate youth about the risks of even intermittent tobacco product use could reduce misperceptions of harm. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Waterpipe tobacco smoking (WTS) continues to be very common in the Eastern Mediterranean Region (EMR), partially because of cultural acceptance but also because of misconceptions of its harm. This paper aimed to describe the beliefs towards waterpipe harm of university students who smoked waterpipe in five EMR countries. METHODS: This study was conducted in 2016 across five EMR countries: Egypt, Jordan, Occupied Palestinian Territories, Oman and United Arab Emirates (UAE). Participants were recruited from among university students in each country. Students' characteristics, smoking behavior, flavor preference and knowledge of WTS harm were collected using an internet-based survey. Participants were included if they were ever waterpipe tobacco smokers and between 18 and 29 years of age. Bivariate analyses assessed variations in student-perceived WTS harm across the countries. Linear regression analysis was used to assess WTS perceived harm differences between students in the different countries. RESULTS: A total of 2 544 university students participated from the five countries. Among ever smoking students, 66% reported WTS in the past 30 days, with the highest proportions (40%) from Occupied Palestinian Territories (OPT) and (41%) Jordan. Dual smoking of waterpipe and cigarettes was highest among students from Egypt. Most participants from the five countries had high level of perceived harm related to WTS during pregnancy. Less than 50% of the students believed that WTS could lead to the death of the smoker, can be harmful for non-smokers and have an addictive effect. Female students, those older than 22 years, and those who didn't smoke waterpipe in the last 30 days significantly had a higher level of WTS perceived harm. Participating students believed that cigarettes are more addictive and contain more nicotine compared to waterpipe. CONCLUSIONS: Misperceptions of waterpipe harm are common among university students in the five EMR countries. Immediate public health action is needed, including enforcement of waterpipe tobacco control regulations along with awareness campaigns. [ABSTRACT FROM AUTHOR]

This study aimed to determine the prevalence and factors associated with hookah smoking and perceptions of harm among U.S. adults. Data were pooled from the Tobacco Products and Risk Perceptions Surveys conducted separately in the summers of 2014 and 2015, among a probability sample selected from an online research panel. Descriptive, logistic regression, and multinomial logistic regression analyses were conducted. In 2014/2015, prevalence of ever and past 30-day hookah smoking among U.S. adults were 15.8% (95% C.I.: 15.0%, 16.7%) and 1.5% (95% C.I.: 1.2%, 1.8%), respectively. Adults who used other alternative tobacco products had a higher odds of hookah smoking than those who did not. Adults with some college education (AOR, 1.53) and with a college degree or more (AOR, 2.21), those identified as non-Hispanic other (AOR, 1.38) were more likely to be ever hookah smokers. Being a young adult (AOR, 2.7), college-educated (AOR, 2.3), never smoker (AOR, 2.1), and an ever hookah smoker (AOR, 2.8) were associated with lower perceptions of harm. Findings suggest that young college students are at higher risk of smoking hookah and that hookah smoking is more prevalent among individuals who use other tobacco products, such as little cigars and cigarillos, traditional cigars, and e-cigarettes, indicating a distinct group of users of alternative tobacco products. Regarding potential harm of hookah, the study highlights a knowledge gap and misperception especially among young, college-educated, and never smokers. Public health interventions should target these subpopulations to provide them with accurate information on hookah smoking. [ABSTRACT FROM AUTHOR]

This study investigates how ENDS harm perception influences ENDS initiation over time among US young people. Data were from the sample of the Population Assessment of Tobacco and Health (PATH) Study conducted from 2013 to 2018. The Cox proportional hazards regression models were used to assess the relationship between absolute (the perception of harm from ENDS only) and relative harm perception (ENDS' harm relative to cigarettes) and ENDS initiation among adolescents (12–17 years) and young adults (18–24 years) separately. Harm perception was assessed at the wave before ENDS initiation in a subsequent wave. Weighted results were reported. Of the 11,633 adolescents and 5089 young adults from baseline, 17.1% and 25.5% initiated ENDS use across four waves, respectively. Among adolescents (HR=2.31; 95%CI: 1.95–2.73) and young adults (HR=1.97; 95%CI: 1.69–2.30), perceiving lower relative harm of ENDS significantly predicted ENDS initiation in subsequent waves. Among adolescents, perceiving lower absolute harm of ENDS (HR=2.18; 95%CI: 1.83–2.60) predicted ENDS initiation in subsequent waves. Additionally, adolescents and young adults who ever used any other tobacco products or alcohol and lived with anyone who used tobacco were more likely to initiate ENDS use. Among a representative longitudinal cohort of adolescents and young adults who had never used ENDS at baseline, perceiving ENDS as reduced or low-harm products significantly predicted ENDS initiation in subsequent waves. These findings underscore the importance of ENDS harm perception and the central role of risk communication strategies that need to target those young people at particular risk of unwarranted ENDS use. • 17.1% of adolescents and 25.5% of young adults initiated ENDS use between 2013 and 2018. • Reduced or low-harm perception of ENDS predicted ENDS initiation. • Ever use of any other tobacco products or alcohol predicted ENDS initiation. • Findings underline the need for appropriate ENDS risk communication interventions. [ABSTRACT FROM AUTHOR]