Comparison of Direct and Indirect Measures of E-cigarette Risk Perceptions

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Olivia A. Wackowski, PhD, MPH
Michelle T. Bover Manderski, MPH
Cristine D. Delnevo, PhD, MPH

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Objectives: Risk perception measures of tobacco products relative to cigarettes are used
commonly and are important to tobacco research, given that they may be associated with, and
predict, tobacco use. However, results may differ based on the actual measures used. This study
compares direct and indirect approaches to measuring e-cigarette/cigarette risk perceptions.
Methods: We compared the responses of 519 current smokers on a nationally-representative
2014 survey that gauged perceptions of e-cigarettes’ harm relative to cigarettes in 2 ways: (1) a
single-item direct measure of comparative harm; and (2) a 2-item indirect measure (which
measured perceived levels of harm from e-cigarettes and cigarettes independently in 2 parallel
questions). Results: We found that 60% of smokers rated e-cigarettes “less harmful” than
cigarettes when using a direct comparative risk measure versus 73% when using an indirect
measure. Agreement between measure types was fair (Cohen’s kappa=0.45) and was lower for
males, Blacks, older smokers, and less educated smokers. Conclusions: E-cigarettes were more
likely to be rated by smokers as less harmful than cigarettes when using indirect versus direct
measures. Additional methodologic research in this area is warranted given the importance of
risk perceptions to tobacco control interventions, communications, policymaking, and regulation.
Key words: e-cigarettes; risk perceptions; survey methods
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Olivia A. Wackowski, Assistant Professor, Rutgers School of Public Health, Center for Tobacco
Studies, New Brunswick, NJ. Michelle T. Bover Manderski, Rutgers School of Public Health,
Center for Tobacco Studies, New Brunswick, NJ. Cristine D. Delnevo, Professor, Rutgers School
of Public Health, Center for Tobacco Studies, New Brunswick, NJ.
Correspondence Dr Wackowski; wackowol@sph.rutgers.edu

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