Belief and Recall of Nicotine as Therapeutic for COVID-19 May Undermine E-Cigarette Quitting Behavior

Abstract

We examine the proposition that misinformation about the therapeutic potential of nicotine to prevent or treat COVID-19 may lead to relapse among attempted e-cigarette quitters. A sample of N = 507 e-cigarette ever-users who reported at least one quit attempt in the past year were surveyed in June of 2021 for recall and belief in several claims about COVID-19 and nicotine. Participants who recalled and believed at least one misinformation claim were significantly more likely to have relapsed than those who did not recall or believe such claims. These differences remained robust to regression analysis adding demographic covariates and accounting for continuous measurement of recall and belief. Misinformation about e-cigarette use is reaching young adult e-cigarette users who are trying to quit. The implications of these findings merit further research to characterize potential barriers to successful e-cigarette cessation.

Keywords

e-cigarettes health behavior quantitative methods vaping

Introduction

Given the high profile of the COVID-19 pandemic, scholars have suggested that the well-known respiratory effects of the severe acute respiratory syndrome coronavirus 2 (SARS COV-2) may incentivize quitting among smokers and vapers (Popova, 2022). However, some data indicate that many e-cigarette (EC)¹ users continued and even increased use rather than quit during the pandemic (Klemperer et al., 2020; Kreslake et al., 2021), suggesting that COVID-19 may present barriers to quitting. Although previous research has found external stressors may prompt EC use during the pandemic (Bommele et al., 2020), misinformation about a protective, preventive, or even therapeutic role of nicotine against COVID-19 identified by previous research (Kavuluru et al., 2021) may motivate relapse among EC users attempting to quit.

Although some suppose the respiratory effects of COVID-19 could prompt EC cessation (Popova, 2022), the evidence supporting this effect is limited. Youth and young adult’s use of ECs likely declined during the pandemic (Wang et al., 2019) with one study identifying a negative association between COVID-19 and EC harm perceptions among a sample of EC users (Kelly et al., 2020). However, the crucial role of product availability caused by stay-at-home orders in facilitating this decline (Kreslake et al., 2021) suggests that the pandemic may not have provided motivation to quit so much as barriers to use, implying declines may be temporary. For example, in a sample of adults, 29% of participants reported increasing their EC use compared to 25% who reported decreasing after learning about COVID-19, and most reported no change (Klemperer et al., 2020).

The uncertainty inherent in the health information environment surrounding COVID-19 and ECs likely poses a barrier to those attempting to quit. Research examining motivators of EC use highlights conflicting positive and negative perceptions about ECs in driving initiation (Majmundar & Moran, 2021) and relapse (Pulvers et al., 2020). All the while, the uncertainty inherent to a health crisis creates an environment where misinformation, specifically the idea that ECs or nicotine can prevent or even treat COVID-19 (Kavuluru et al., 2021; Majmundar & Moran, 2021), can disseminate rapidly. One study asking EC users how the pandemic impacted their behavior identified “protection from COVID-19” as 1 of 10 reasons for increased purchase and use of ECs (Soule et al., 2020). This study examines the prospect that recalling such information and believing it to be true may be associated with relapse.

Misinformation about a protective role of nicotine against a threat like COVID-19 is likely to promote relapse among attempted quitters. The importance of addressing beliefs about the harms of using ECs is a focus of theory-driven messaging to deter initiation (Sangalang et al., 2019). As a result, targeting beliefs regarding the benefits of quitting are crucial to effective cessation programs (Gaiha et al., 2020). Conversely, misinformation about an unsubstantiated benefit of EC use during a time when reminders of what one has to gain through quitting are most needed likely undermines a key motivation for quitting ECs. This research examines whether EC users who recalled and believed such misinformation were more likely to have relapsed during their most recent quit attempt.

Methods

Procedure

A sample of ever-EC users who reported a quit attempt in the past year responded to a survey assessing past 30-day EC use as well as recall and belief in misinformation claims identified by previous research (Kavuluru et al., 2021; Soule et al., 2020). Past 30-day use of ECs was used to infer either quitting success or relapse. The total number of recalled and believed claims about the ability of ECs or nicotine to prevent or treat COVID-19 was compared between those who relapsed and those who did not. Data was collected from May 13 to 25, 2021. All participants provided informed consent prior to initiating the survey consistent with the determined exempt Institutional Review Board (IRB) protocol.

Sample

The analytic sample for this study is a purposive subsample of 18- to 34-year-old EC users who reported at least one quit attempt in the past year (n = 507), drawn from a larger sample of ever-EC users (n = 1225) recruited through Qualtrics. Qualtrics maintains an online opt-in panel of respondents who participate in studies for which they meet screening requirements in return for a small cash incentive. Those reporting at least one quit attempt were 56.6% female, 69.4% white, 13.5% non-Hispanic Black, 17.1% Hispanic, and a mean age of 26.9 (SD = 4.8). Moreover, 40.8% reported attaining a high school diploma/ General Educational Development (GED) or lower.

Measures

Quit and Relapse

The analytic sample was segmented based on current 30-day use, wherein those reporting a quit attempt in the past year and reporting no use in the previous 30 days were considered successful quitters, and those reporting a quit attempt but also past 30-day use were considered to have relapsed (Mills et al., 2021). Altogether 63% (n=317) of the analytic sample relapsed while 37% (n = 190) had successfully sustained their quit attempt for at least the past 30 days.

Misinformation

Misinformation was operationalized as a combination of recall of previous exposure to three claims about the protective role of nicotine, and belief in whether four claims about nicotine and ECs as protective against COVID-19 were true. The three recall items asked participants about nicotine, specifically, rather than ECs, because the early pandemic research citing a lower-than-expected number of smokers admitted to the ICU (Farsalinos et al., 2020) was commonly referenced to support such misinformation in previous studies (Kavuluru et al., 2021; Soule et al., 2020). The subsequent belief items asked whether participants believed claims about both nicotine as a protective agent against COVID-19 as well as if ECs specifically could be used to treat or prevent COVID-19. Table 1 provides all question wording and descriptives for recall and belief in misinformation.

Table 1.

Descriptives for Recall and Belief in Misinformation About COVID-19 and Nicotine (n = 507).

Recall (n = 507)
Have you heard about the following claims prior to today?	Yes	No	Don’t know	Total
Have you heard about the following claims prior to today?	n (%)	n (%)	n (%)	n (%)
Nicotine can help cure those with COVID-19	59 (11.7%)	396 (78.3%)	51 (10.1%)	506 (99.8%)
Nicotine reduces the severity of COVID-19	66 (13.0%)	362 (71.4%)	79 (15.6%)	507 (100%)
Doctors and nurses have been using nicotine replacement therapy (gums and patches) to protect themselves from COVID-19	100 (19.9%)	274 (54.5%)	129 (25.7%)	503 (99.2%)
Beliefs (n = 507) ^a
How true do you believe the following claims to be?	Probably or definitely true	Unsure	Probably or definitely not true	Total
How true do you believe the following claims to be?	n (%)	n (%)	n (%)	n (%)
Nicotine can help cure those with COVID-19	46 (9.1%)	74 (14.7%)	383 (76.1%)	503 (99.2%)
Nicotine can reduce the severity of COVID-19	51 (10.1%)	80 (15.8%)	374 (74.1%)	505 (99.6%)
Vapers have a lower risk of contracting COVID-19	54 (10.7%)	69 (13.7%)	381 (75.6%)	504 (99.4%)
Vapers have a lower risk of severe complications from COVID-19	58 (11.5%)	86 (17.0%)	362 (71.5%)	506 (99.8%)

Five response options were given: (1) Definitely not true, (2) Probably not true, (3) Unsure, (4) Probably true, and (5) Definitely true. These response options were grouped for analysis.

Analyses

We conducted two sets of analyses, of increasing scrutiny, to test the premise that recall and belief in misinformation is associated with EC relapse for those who have recently tried to quit. The primary analysis included a simple comparison of the percentage of people who relapsed, using easily interpretable categories: Unaware (did not recall or believe any misinformation), recallers (recalled one or more claims, but did not believe any), believers (did not recall any claims, but believed at least one), and recall-believers (recalled and believed at least one claim). Two-proportion z-tests were used to assess the likelihood that observed differences in the percentage who relapsed between groups were due to chance. These analyses had two notable limitations: (1) Cross-sectional comparison across categories does not allow for random assignment. As a result, individual differences that are also likely related to relapse may be driving observed differences between categories. (2) Although a participant can theoretically recall between zero and three claims and believe between zero and four claims, our categorical comparisons do not distinguish by degree.

To address the limitations of a simple test of comparison, we also conduct binary logistic regression analysis to control for individual differences and examine both recall and belief in misinformation claims as continuous predictors of relapse. We used binary logistic regression predicting the odds of relapse with robust standard errors to estimate 95% confidence intervals. Continuous measures of recall (0–3) and belief (0–4) were the independent variables of interest. Age (continuous), and dummy codes for female, non-Hispanic Black, Hispanic, and having a high school diploma/GED or lower education were included as covariates known to affect tobacco use (Centers for Disease Control and Prevention, 2015).

Results

Categorical Analysis

Table 2 provides descriptives for participants who were unaware, recallers, believers, and recall-believers of misinformation, and the percentage of each of those groups who relapsed from their quit attempt. Recallers were marginally more likely to relapse than unaware, z = 1.84, p = .066. Believers, of whom there were very few, were not statistically different in their likelihood of relapse from unaware, z = 0.18, p = .856. Finally, recall-believers were significantly more likely to relapse than unaware participants, z = 3.877, p < .001.

Table 2.

Group Comparisons of Relapse by Recall and Belief in Misinformation About COVID-19 and Nicotine (n = 507).

Group	% of sample	Within group % relapsed
Group	n (%)	n (%)
Unaware^a	331 (65.3%)	190 (57.4%)
Recallers^b	77 (15.2%)	53 (68.8%)
Believers^c	27 (5.3%)	15 (55.6%)
Recall-believers^d	72 (14.2%)	59 (81.9%)

Those who were neither recalled nor believed any of the mentioned claims. ^bThose who recalled at least one claim, but did not believe any. ^cThose who believed at least one claim, but did not recall any. ^dThose who recalled at least one claim and believed at least one claim.

Logistic Regression

As a robustness check for the above analyses (Centers for Disease Control and Prevention, 2015), binary logistic regression analyses showed a small but significant negative relationship between age and relapse (odds ratio [OR] =0.94, 95% confidence interval [CI] = 0.90, 0.97). However, being female (OR = 1, 95% CI = 0.68, 1.47), Black (OR = 1.45, 95% CI = 0.81,2.61), or having lower education (OR = 0.89, 95% CI = 0.60, 1.31) were not associated with relapse. Hispanic ethnicity was associated with more than twice the odds of relapse (OR = 2.21, 95% CI = 1.27, 3.85). Prior to adding misinformation beliefs to the model, the odds of relapse increased by 63% for every piece of misinformation recalled (OR = 1.63, 95% CI = 1.21, 2.19). However, when belief was added to the model, the OR for recall was no longer significant. Rather, the model suggests that holding recall constant, every piece of misinformation a participant believed was associated with a 55% increase in odds of a relapse (OR = 1.55, CI = 1.19, 2.03).

Discussion

This study provides robust evidence that recall and belief in misinformation about a potential protective role of nicotine are associated with relapse from an EC quit attempt. Although those who relapsed were on average, significantly younger, the difference in real terms was negligible. Moreover, as our sample ranged between 18 and 34 years old, we caution over-interpretation of findings related to age. In contrast, Hispanic participants were more than twice as likely to relapse as non-Hispanic participants. It is possible Hispanic users may seek fewer cessation resources or trends may be a result of minority stress (Sonnenfeld et al., 2009). This unanticipated finding highlights the need for future research examining how experiences unique to Hispanic EC users may pose additional challenges to quitting.

This study is unique in that it examines the relationship between misinformation and quitting behavior among young adults who had already decided to quit. Nearly one in three reported recalling or believing at least one false claim that either nicotine or ECs could protect them from COVID-19, while nearly one in five believed that either nicotine or EC use was a positive health behavior during this pandemic. This finding underscores the fact that misinformation can undermine public understanding of the continuum of risk of tobacco products (Soule et al., 2020). While there is ample evidence that misinformation about ECs can promote uptake and progression and that COVID-19 risk perceptions may motivate the desire to quit, our findings suggest that misinformation may influence the success of quit attempts and prompt relapse. If such misinformation serves to facilitate nicotine addiction and thwart efforts to quit, further research is needed to identify messages for dissemination that help counter these claims.

Our findings highlight the importance of countering health misinformation about COVID-19. Designers of prevention and cessation programs should consider including claims explicitly focused on countering misinformation about the alleged health benefits of nicotine including inoculation against misinformation, news literacy campaigns, and expert correction (Donovan, 2020).

Although by no means limited to social media, the role of social media in spreading the misinformation identified in this research is well-established (Kavuluru et al., 2021; Soule et al., 2020). Moreover, as an increasing number of EC users report wanting to quit (Cuccia et al., 2021; Rosen & Steinberg, 2020) yet struggle to find information tailored to quitting ECs, social media is a highly utilized source of health information (Sanchez et al., 2021). Although seeking information can be a positive health behavior, signaling an active interest in behavior change, our findings highlight a double-edged sword. Previous research showed that information seeking about ECs can lead to product use and initiation (Yang et al., 2019). Our study highlights the need for further research on the motivations underlying information seeking in this context, as those trying to quit may stumble upon misinformation while looking for quitting resources or actively seek information that affirms their desire to abandon their quit attempt. Thus, it is crucial to provide easily accessible information specific to EC cessation on platforms where people who search for EC information are likely to find it, as well as continue research that furthers our understanding of how to effectively disseminate accurate information with easily identifiable credibility heuristics in a user-driven information environment where the motivations underlying information seeking are not necessarily conducive to positive health behaviors.

Limitations and Future Directions

Although these findings are important, they are subject to limitations. First, this study employs a cross-sectional convenience sample which cannot be used to infer causal relationships or be representative of a population. Similarly, using a sample recruited through online, opt-in panels limits external validity. Finally, self-reported data are subject to recall and social desirability biases.

Conclusions

This study provides evidence for a significant relationship between misinformation and EC relapse. Misinformation about EC use is clearly reaching young adult EC users and is likely serving to exacerbate nicotine addiction among young people.

Footnotes

Acknowledgements

The authors would like to thank Michael Amato for his helpful feedback on this manuscript.

Author Contributions

N.S. conceptualized the study. N.S. and E.K. developed the data collection tool. N.S. analyzed the data. N.S., E.K., B.T., L.S., and D.V. contributed to the development and writing of the manuscript. B.S. and D.V. oversaw the project. All authors reviewed the manuscript and offered comments prior to submission.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Elexis Kierstead

Data Statement

The data used in this study is housed at Truth Initiative. Any requests to access the data can be addressed to the corresponding author.

Notes

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