Conditional risk assessment of adolescents' electronic cigarette perceptions.

How individuals perceive the potential positive and negative consequences of their actions is an important component of health decision models and a key predictor of future behavior and behavioral intentions.1,2 Among adolescents, perceived risks and benefits have both been associated with intentions to engage in risk-taking,3 including the use of illegal drugs and other substances.4,5 Measurement instruments that capture adolescents’ perceptions provide data that offer insight into the decision-making process regarding health behaviors, which can lead to more effective health promotion. In the US, about 6000 people per day smoke cigarettes for the first time, and individuals under age 18 years account for about half of new users.6 Among high school students, those who have smoked cigarettes estimate lower probabilities of negative consequences and higher probabilities of positive social returns related to smoking.7 Moreover, lower levels of perceived smoking-related risks and higher levels of perceived benefits are associated with subsequent smoking initiation among adolescent non-smokers.8 Among adolescent smokers, lower perceived risks correspond to greater promotion of smoking among their peers.9 Thus, understanding adolescents’ risk and benefit perceptions related to cigarette use has implications for creating more effective, evidence-based anti-smoking interventions and regulations that target perception formation. However, cigarettes account for only a portion of adolescent tobacco use. While cigarette smoking is declining among US high school male students,10 there is increasing use of alternative tobacco products; in particular, electronic cigarette use is rising rapidly.10-13 Some adolescents who have tried electronic cigarettes have never smoked cigarettes,14 suggesting that adolescents may initiate tobacco use with electronic cigarettes. The health impact of growing electronic cigarette popularity among youth is largely unknown15 but increasingly stated as a public health concern.16,17 With neither a scientific nor popular consensus as to long-term effects, adolescents’ reliance on their own risk and benefit perceptions may take on greater importance in their decision to use electronic cigarettes. Scant published data exist with regard to measuring adolescent risk perceptions in the context of electronic cigarettes. Recent studies have asked adolescents and/or young adults to compare the overall harm of electronic cigarettes to cigarettes. In Poland, more than half of high school and university survey respondents believed that electronic cigarettes were safer than conventional cigarettes.11 Among college and university students in Hawaii, lower electronic cigarette harm perceptions were correlated with past-30 day electronic cigarette use and with greater receptivity to electronic cigarette marketing.18 Among US middle and high school students, current cigarette smokers were more likely than never-smokers to rate electronic cigarettes as less harmful than cigarettes.19,20 In one prospective study, both among cigarette smokers and non-smokers, young adults who perceived electronic cigarettes to be less harmful than cigarettes were more likely to try electronic cigarettes at 6-month follow-up.21 While providing valuable insights, these studies relied on unconditional measures of perceived risk, in which participants were asked to assess electronic cigarettes generally, without any context to anchor potential electronic cigarette use to what they might experience personally. In contrast, conditional risk assessment, in which participants are asked to consider future outcomes under the condition, often hypothetical, that they engage in a particular behavior (eg, “What is the chance you will get sick if you were to smoke daily?”), has been shown to be a superior indicator of behavior.7,22 Furthermore, indirect risk comparison items, in which stand-alone risks or benefits of various tobacco products are assessed in separate questions, could reveal underlying differences in beliefs more readily than direct comparison items, in which participants are asked about products side-by-side and in relation to each other.23 Finally, measures that ask participants to consider multiple outcomes, including health risks and social risks, as well as possible benefits, yield a more detailed inventory of the expectations potentially shaping tobacco-related behaviors than would measures that assess perceived harm in general.7 The primary objective of this study was to adapt an instrument previously validated for measuring adolescent risk and benefit perceptions related to cigarettes for application in measuring adolescent risk and benefit perceptions related to electronic cigarettes. We hypothesize that the new conditional risk assessment instrument will effectively measure multiple perceived risks and benefits related to electronic cigarettes and that these perceptions will be associated with reported behavior. Specifically, based on prior theory1,2 and analogous to associations demonstrated for cigarettes,7,8 we anticipate lower perceived probability of future risks and higher perceived probability of future benefits among ever-users compared to never-users of electronic cigarettes, as well as lower perceived risks and higher perceived benefits among never-users who report intention to use electronic cigarettes in the future. Our expectation is that this adapted conditional risk assessment instrument will allow for future studies of the relationships between adolescents’ risk and benefit perceptions and their electronic cigarette behaviors, as well as support side-by-side comparisons of adolescents’ perceived risk and benefit profiles of electronic cigarettes and combustible cigarettes.