Electronic cigarettes, commonly known as e-cigarettes or vapes, have transformed the landscape of tobacco use in the United States over the past decade. Once considered a safer alternative to combustible cigarettes, e-cigarettes have become the subject of intense public scrutiny due to emerging health concerns, regulatory actions, and media coverage. Understanding how the public perceives the risks of vaping is critical for shaping public health strategies, educational campaigns, and tobacco harm reduction initiatives.
A 2026 study by Wu, Son, Lee, Pruitt, Ahn, Balis, Minna, Thomas, and Gerber, published in Nicotine & Tobacco Research, examined the evolution of public perception regarding e-cigarettes over a ten-year period in the United States. By analyzing data from the Health Information National Trends Survey (HINTS) collected from 2012 to 2022, the researchers shed light on how awareness of vaping-related health risks has influenced adult attitudes. This study provides important insights for clinicians, policymakers, and public health professionals striving to balance prevention of youth nicotine use with support for adult smoking cessation.
E-cigarettes emerged in the early 2000s as a novel method for delivering nicotine without the combustion of tobacco. Unlike traditional cigarettes, which produce smoke containing thousands of toxic chemicals, e-cigarettes vaporize a nicotine-containing liquid. This process reduces exposure to some harmful substances found in combustible tobacco, making e-cigarettes appealing to adult smokers seeking alternatives or attempting to quit smoking.
Over time, e-cigarettes have become the second most commonly used tobacco product in the United States after combustible cigarettes. Young adults have particularly embraced vaping, contributing to increased attention from regulators and public health organizations. Despite their potential for harm reduction, e-cigarettes carry risks including nicotine addiction, respiratory irritation, and uncertain long-term effects on lung health. These risks have been central to the debate on how best to regulate vaping products and educate the public.
Public perceptions of e-cigarettes have been shaped by several national campaigns and high-profile events. The U.S. Food and Drug Administration’s (FDA) Real Cost Campaign, initially targeting cigarette smoking, expanded in 2018 to include messaging specifically about e-cigarettes. Around the same time, the FDA officially recognized youth vaping as an epidemic, emphasizing the urgent need to prevent nicotine initiation among adolescents. These initiatives were amplified by media coverage and public discourse, raising awareness of potential harms associated with vaping.
A pivotal event that influenced public perception was the outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) in 2019. Initially, the cause of EVALI was unclear, prompting widespread concern about all vaping products. Later research linked EVALI primarily to tetrahydrocannabinol (THC) vaping products containing vitamin E acetate. Nevertheless, the incident underscored that vaping is not risk-free and highlighted the potential dangers of unregulated or adulterated products. The public response to EVALI demonstrates how health crises can rapidly alter perceptions, sometimes with lasting effects.
The HINTS study provides a detailed picture of how perceptions of e-cigarettes have changed among U.S. adults. In 2012, only 2.8 percent of adults believed e-cigarettes were more harmful than combustible cigarettes. By 2022, that number had risen dramatically to 30.4 percent. Conversely, the percentage of adults who perceived e-cigarettes as less harmful decreased from 50.7 percent to 16.7 percent during the same period.
These shifts were not limited to a single demographic group. Adults of all ages, genders, racial and ethnic backgrounds, and smoking status categories demonstrated similar trends. The most pronounced changes occurred between 2018 and 2022, corresponding with the Real Cost anti-vaping campaign expansion and the EVALI outbreak. After the anti-vaping campaign rollout, the proportion of adults viewing e-cigarettes as more harmful increased by 3.5 percent. Following the EVALI outbreak, this proportion jumped by 12 percent. These figures suggest that public health campaigns and media coverage have a measurable impact on adult perceptions of vaping risk.
Understanding public perception of e-cigarettes is critical for tobacco control strategies, particularly for adults who smoke. Research shows that individuals who perceive e-cigarettes as more harmful than combustible cigarettes may be less likely to use them as a tool for quitting smoking. While e-cigarettes are not risk-free, they are generally considered less harmful than combustible cigarettes for adult smokers seeking alternatives. Consequently, the perception that e-cigarettes are equally or more harmful could discourage smokers from switching, potentially resulting in continued cigarette use rather than harm reduction.
This creates a challenge for public health messaging. Campaigns that aim to prevent youth vaping and reduce nicotine addiction among adolescents must balance the need to convey risks without inadvertently discouraging adult smokers from adopting safer alternatives. Clear, evidence-based communication that differentiates between absolute and relative harm is essential for supporting adult harm reduction while protecting vulnerable populations.
The HINTS study highlights the powerful role of media and public health campaigns in shaping perception. The increase in perceived harm coincided with high-profile media coverage of EVALI and national campaigns emphasizing vaping risks. While media attention is effective for raising awareness, it can also amplify fear and misperception if not paired with nuanced messaging.
For example, media coverage often generalized the risks of THC-related lung injury to all e-cigarette products, potentially leading the public to overestimate the danger of regulated nicotine vaping products. Public health campaigns should aim to present accurate, nuanced information that distinguishes between different products and relative risks, ensuring that adults can make informed choices while still discouraging initiation among youth.
The study has limitations worth noting. It excluded individuals under 18, leaving a gap in understanding youth perceptions, which are critical given the high rates of vaping in this age group. Additionally, the observational nature of the research means that causation cannot be definitively established. While there is a strong correlation between anti-vaping campaigns, EVALI awareness, and changes in perception, other factors such as local regulations, community programs, and social media influence may also have contributed.
Future research should explore adolescent and young adult perceptions, as well as longitudinal behaviors following shifts in public awareness. Understanding how public perception affects actual use patterns and cessation outcomes will provide more actionable insights for policymakers and health professionals.
The findings of the HINTS study provide guidance for shaping future public health campaigns. Effective communication should achieve three key objectives:
Incorporating these strategies into national and local campaigns can help maximize the public health benefits of tobacco control while minimizing unintended consequences. Public perception plays a significant role in shaping behaviors, and nuanced messaging can guide individuals toward safer choices.
Over the past decade, public perceptions of e-cigarettes have changed dramatically in the United States. Once considered less harmful by a majority of adults, e-cigarettes are now increasingly seen as dangerous or equally harmful compared to combustible cigarettes. These changes appear to correspond with national anti-vaping campaigns and heightened awareness of vaping-related health risks, such as the EVALI outbreak.
For public health professionals and policymakers, these findings underscore the need to strike a careful balance in messaging. Campaigns must protect youth from nicotine initiation while providing adults with accurate, evidence-based information about relative risks and cessation options. Continued monitoring of public perceptions and evaluation of educational campaigns will be crucial to ensure effective tobacco control and harm reduction strategies in the years to come.
This blog is intended for informational purposes only and summarizes research findings from a published journal article. It does not provide medical advice. Readers should consult healthcare professionals for guidance related to smoking cessation, vaping, or personal health concerns.
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