The harmfulness and the addictiveness of nicotine products: Two separate but related constructs

The scientific evidence that nicotine is an addictive drug is largely undisputed, and over the past decade around 85% of US adults agree with statements that nicotine is addictive. Most tobacco products have included a rotating health warning, including one stating that the product contains nicotine, an addictive drug. However, the scientific evidence that nicotine directly causes the major smoking-related diseases is much weaker, and this is widely misunderstood.

Scientific evidence indicates a risk continuum among nicotine products, with smoked nicotine products (mainly cigarettes) being considerably more harmful to health than non-smoked alternatives. In the USA, adults have become significantly more misinformed about the relative harmfulness of e-cigarettes compared with cigarettes over time (e.g., in 2012, 51% believed e-cigarettes were less harmful; by 2022, only 17% held that view). Much of the public’s misunderstanding stems from confusion over whether nicotine causes specific deadly diseases, such as cancer (it does not). A recent study of adults who believe e-cigarettes are at least as harmful as cigarettes found that 79% agreed that “Vapes have nicotine just like cigarettes, so they would cause the same diseases.” The magnitude of the problem was made clear when a survey of 926 US physicians found that many wrongly believed that “nicotine on its own directly contributes to the development of cancer” (which is not true). Additionally, 79% agreed that it directly causes COPD. The authors stated: “the proportion of surveyed physicians who believe that nicotine directly contributes to these health outcomes is alarmingly high. It is possible that participants are conflating the addictive effect of nicotine with the comparatively more harmful [health] effects of tobacco use,”

Core principles of public health education include: (1) it should be based on accurate science, i.e. the truth; (2) it should be both understandable and actionable; and (3) it should avoid misleading or exaggerated claims and respect the public’s right to use it as they wish, i.e., autonomy. Many countries around the world have done a very poor job of applying these principles to health education concerning the continuum of risk.