In recent years, the widespread introduction of e-cigarettes has transformed the landscape of tobacco use and public health discussions. These devices, which deliver nicotine through vapor rather than smoke, are often presented as a less harmful alternative to combustible cigarettes. However, public perception surrounding their safety has been deeply complicated by events such as the 2019 outbreak of e-cigarette or vaping product use-associated lung injury (EVALI). This health scare captured significant media attention, shaping beliefs and attitudes about vaping risks in ways that persist today. Recent scientific analysis from the Medical University of South Carolina (MUSC) offers crucial insights into how risk perceptions have shifted and the broader implications for smoking cessation efforts and health disparities.
E-cigarettes occupy a nuanced position within the spectrum of tobacco products. While they are not devoid of health risks, established evidence supports the U.S. Food and Drug Administration’s recognition of a “continuum of risk.” This continuum places combustible cigarettes at the highest end due to the intense toxicant exposure from burning tobacco, which generates thousands of harmful chemicals and known carcinogens. By contrast, e-cigarettes typically deliver nicotine through aerosolized e-liquids, exposing users to fewer and often lower concentrations of toxic substances. Despite this, a growing number of Americans have come to view e-cigarettes as equally or more harmful than traditional smoking—a misunderstanding that complicates tobacco harm reduction strategies.
The 2019 EVALI epidemic marked a turning point in public perception. This sudden appearance of severe lung illnesses primarily linked to vaping products precipitated alarm and confusion. Initial news reports often failed to discriminate between nicotine-containing e-cigarettes and illicit tetrahydrocannabinol (THC) vaping products adulterated with vitamin E acetate, the agent later identified as the principal cause of EVALI. As a result, the generalized fear engulfing vaping products broadly influenced smokers’ and nonsmokers’ risk assessments, frequently equating the dangers of vaping with those of combustible tobacco, despite scientific evidence to the contrary.
Researchers at MUSC, led by Dr. Tracy Smith, utilized data from a robust nationwide randomized controlled clinical trial spanning from 2018 to 2022. This trial, involving over 600 adult smokers, provided a unique longitudinal perspective on how shifting media narratives and emerging scientific knowledge influenced personal health risk perceptions related to cigarettes and e-cigarettes. Participants rated the perceived personal harm of both products on a scale from zero to ten, enabling a nuanced measurement of relative risk perception over time.
The findings reveal that during and following the EVALI outbreak, participants significantly elevated their perception of e-cigarette risk relative to combustible cigarettes. This heightened perception did not abate even as public health authorities clarified that EVALI was predominantly caused by vitamin E acetate in illicit THC vapes rather than standard nicotine e-cigarettes. Dr. Smith notes that the initial alarming media exposure had a persistent psychological impact, often referred to as the “first impression effect,” whereby early information frames continued to shape beliefs despite subsequent corrections.
Importantly, this shift did not affect all demographics equally. Non-white participants exhibited a more pronounced increase in perceived e-cigarette risk during and after the EVALI crisis, while perceptions among white participants remained comparatively stable. This asymmetric risk perception shift is particularly concerning because racial and ethnic minority groups already experience disproportionate burdens of tobacco-related morbidity and mortality. Such misperceptions could inadvertently discourage smokers in these populations from considering e-cigarettes as an alternative, potentially exacerbating existing health disparities.
The complexity of communicating tobacco-related risks is underscored by these differing perceptions. While e-cigarettes are not without harm—including the risk of ongoing nicotine dependence—their use among current smokers as a cessation aid may offer benefits by reducing exposure to the myriad carcinogens associated with combustion. Public health messaging, therefore, must balance discouraging e-cigarette uptake among nonsmokers and youth while supporting harm reduction strategies for established smokers who struggle to quit using traditional methods.
MUSC’s study underscores the vital role of transparent and precise media reporting. The conflation of nicotine vaping products with illicit THC products during the EVALI outbreak fueled misperceptions that linger. Clear communication distinguishing the diverse products and their respective risk profiles is essential to inform public understanding and guide behavior. Dr. Smith emphasizes that healthcare providers play a critical role in these conversations, helping smokers weigh the benefits and drawbacks of e-cigarettes within the context of their quit attempts.
At MUSC Hollings Cancer Center, dedicated programs provide comprehensive tobacco cessation support, including counseling and medication, tailored to individual needs. These initiatives recognize the difficulty many smokers face when attempting to quit—success rates even with FDA-approved therapies are limited. For those unable to quit immediately, the controlled use of e-cigarettes with the explicit goal of completely transitioning away from combustible tobacco may represent a pragmatic interim strategy to reduce harm.
The stakes are especially high in cancer care, where smoking remains the leading preventable cause of death. Approximately one in three cancer fatalities in the United States is attributable to smoking-related causes, while quitting smoking significantly improves treatment outcomes and long-term survival. Early detection programs, such as lung cancer screening offered at Hollings, complement cessation efforts to reduce morbidity and mortality.
Ultimately, this research sheds light on how risk perceptions, shaped by media narratives and public discourse, influence individual health choices. The persistent elevated perception of e-cigarette harm following the EVALI outbreak may influence smokers’ willingness to consider less harmful alternatives. Understanding these dynamics is crucial for clinicians, policymakers, and researchers aiming to reduce the global burden of tobacco-related disease through informed, evidence-based strategies.
Effective tobacco control must evolve to incorporate emerging scientific evidence and adept communication practices. By addressing misperceptions and tailoring interventions sensitive to cultural and demographic contexts, public health initiatives can better support smokers in achieving complete cessation. The future success in reducing smoking-related illness may well hinge on how precisely we convey risk, empower informed choices, and navigate the complex terrain between relative harms in tobacco use.
Subject of Research:
People
Article Title:
Shifting perceptions of e-cigarette risk: A secondary analysis from a nationwide, randomized controlled clinical trial of e-cigarettes among smokers
News Publication Date:
15-Mar-2026
Web References:
https://hollingscancercenter.musc.edu/
https://www.sciencedirect.com/science/article/pii/S0306460326000821
https://researchers.hcc.musc.edu/ProfilePage?id=smithtra
https://medicine.musc.edu/departments/psychiatry-behavioral-sciences/divisions/addiction-sciences/education/predoctoral/drug-abuse-research-training
https://hollingscancercenter.musc.edu/outreach/sc-cheer-yes
https://www.sciencedirect.com/science/article/pii/S258953702300319X
https://muschealth.org/medical-services/tobacco-treatment-program
https://hollingscancercenter.musc.edu/patient-care/cancer-types/lung-and-thoracic-cancer/screening
References:
Smith, T., Barros, E., Ravenel, I., Carpenter, M. (2026). Shifting perceptions of e-cigarette risk: A secondary analysis from a nationwide, randomized controlled clinical trial of e-cigarettes among smokers. Addictive Behaviors. DOI: 10.1016/j.addbeh.2026.108672
Image Credits:
Medical University of South Carolina; Photo by Clif Rhodes
Keywords:
E-cigarettes, vaping, smoking cessation, EVALI, risk perception, tobacco harm reduction, public health communication, health disparities, nicotine dependence, lung injury, tobacco-related disease, media influence
