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Correcting physicians’ misperceptions around tobacco and nicotine is imperative in correcting the public’s misperceptions. Photo credit: RDNE Stock project
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Misperceptions continue to swirl around tobacco and nicotine. Photo credit: PxHere
Misperceptions tend to go hand in hand with misunderstandings, both of which can influence behavior and lead to potentially dangerous outcomes. When misperceptions are spread at a mass level, this can have even more severe repercussions. Misperceptions around tobacco and nicotine are a good example of this.
One of the most prevalent misperceptions is that all tobacco and/or products containing nicotine are equally bad for one’s health and cause cancer as well as heart and respiratory diseases. Another misperception is that the industry is targeting young people, “luring” them into using cigarettes and other products through marketing tactics and flavors. And, that vaping nicotine is just as harmful as smoking, if not even more so. These are but a few of the more often repeated misperceptions, despite a body of scientific evidence that indicates otherwise.
Moderating a panel at a recent global forum, David Sweanor, public health advocate and adjunct professor of law at the University of Ottawa, said, “There’s all this misperception and we’re stuck in the situation where when we look at consumers, or [at regulators], there’s a truism which is that people can only make as good a decision as the information available to them allows. And if people have inadequate information, they make poor decisions, then there’s the tendency to blame them for having made a poor decision [such as] somebody continuing smoking or a legislator pushing a law that’s actually counterproductive.”
Dr. Delon Human, a physician and president of Health Diplomats and who was on the same panel, pointed out that, “at the heart of nicotine misperception lies the issue that we are wasting unnecessary lives. We are allowing the misperception of nicotine to lead to disease.”
Ironically, these views are largely perpetuated by those who are purportedly working to prevent disease and unnecessary loss of lives, such as the World Health Organization (WHO), health ministries, public health officials and physicians, as well as anti-tobacco activists and organizations. Unfortunately, these groups also wield enough power and influence to control the narrative and dismiss, condemn, or block any dissenting voices, scientific or not.
For the general public, what information they receive tends to come from media channels and, even more so when it comes to health-related information, from their doctors. This seems innocuous enough, unless these doctors and other healthcare practitioners happen to have skewed views themselves, aligning their beliefs with the information coming from “authoritative” and “trustworthy” agencies such as WHO, the Food and Drug Administration (FDA), or approved publications.
In 2020, a study by Michael B. Steinberg et al published in the Journal of General Internal Medicine surveyed more than 1,000 US specialist physicians in family medicine, internal medicine, obstetrics and gynecology, cardiology, pulmonary and critical care, and hematology and oncology about what they knew about tobacco treatment practices, harm reduction beliefs, and tobacco and e-cigarette use. A staggering 80% believed nicotine directly causes cancer; 83% strongly believed nicotine directly contributes to heart disease; and 81% believed nicotine contributed to chronic obstructive pulmonary disease (COPD). Interestingly, pulmonologists were less likely than other specialties to believe nicotine directly contributes to COPD, and family doctors were more likely to believe nicotine caused cancer than oncologists.
Fast-forward to August this year, when Roger Bate, a senior scholar with the International Center for Law & Economics (ICLE), published his research surveying US and UK physicians to see if government policy has an effect on their knowledge and opinion of nicotine. Bate chose to compare the two groups as he viewed the UK government as being more supportive of vaping and other nicotine replacement methods, compared to the US government.
The study found the majority of doctors are aware that nicotine does not cause cancer, however considerably more doctors in the US than in the UK still hold the wrong belief. Additionally, surveyed UK physicians had a much more positive opinion of vaping as a smoking-cessation aid than their US counterparts.
Approximately one-third of the US doctors surveyed believe nicotine is carcinogenic in any form other than nicotine replacement therapies (NRT) whereas fewer than 1 in 10 UK doctors believe so, supporting Bate’s hypothesis that the previous study’s estimate of more than 80% was based on many participants misreading the question. However, almost 60% of these American doctors believe that FDA-approved smoking cessation aids are not significantly safer than cigarettes. The majority (64%) of US physicians believe that only conventional NRT such as patches, gum, and lozenges are significantly safer than smoking.
“There is a misunderstanding that nicotine is carcinogenic and that vaping products are as dangerous as smoking, which is simply not supported by available scientific data,” Bates wrote. “But to a considerable extent, this is the fault of FDA and [the US Centers for Disease Control and Prevention] CDC, due to their equivocal stance on the value of vaping as a smoking-cessation tool. Most physicians sampled in both nations want their health authority to correct misperceptions and US authorities are not doing so.”
Correcting misperceptions
There is a glimmer of hope, though, that a course correction is possible, if all stakeholders are able to recognize what is wrong and willing to make the necessary changes. In an Addiction article published on August 15, Brian King, director of the US Food and Drug Administration (FDA) Center for Tobacco Products (CTP), and Benjamin Toll wrote “tobacco products exist on a continuum of risk, with smoked products, such as cigarettes, having the greatest risk.” The fact that the head of CTP acknowledges that different tobacco products have different levels of risk is a positive sign. Also encouraging is the fact that he also acknowledged that there are opportunities FDA can improve its communication in its efforts to educate the public about the relative risks of tobacco products using evidence-based approaches, and that FDA recently started formative research to guide possible messages related to misperceptions about nicotine and the continuum of risk among adult smokers.
At the physician level, as Dr. Delon Human suggested at the forum, change can be affected through training and better understanding of harm reduction. “Training needs to be updated to the 21st century,” he said. “Doctors need to know that nicotine does not cause cancer. It’s a crime for doctors to think that nicotine causes cancer or heart disease or lung disease the way that they perceive it now.”
“[Also] make sure that doctors understand what harm reduction is. Harm reduction is really part of everyday medical life. That’s what we do in medical practice – you try and reduce the harm.”
The industry also shares a responsibility in correcting these misperceptions, even though it often seems like a futile effort. Continuing to develop innovative products through r&d that are based on science, working together with government and non-government agencies to ensure safer products end up in consumer hands, and always listening to consumers remain the industry’s greatest strengths.
As David Sweanor poignantly said, “You want to understand people’s lived experience, you need to meet them where they are, and you need to empower them to make better decisions. We constantly get that wrong by moving into things like deciding that we need to use the power of the state to impose our moral views on the behaviors of others, which is a strategy that never works, it’s almost always a disaster, and we keep doing it.”