Nicotine is the drug that keeps people coming back to cigarettes but not the substance that causes serious health effects in people who use tobacco. It is the tar and toxic chemical mix in tobacco and tobacco smoke that causes cancer, lung disease and 490,000 deaths in the U.S. each year.
Researchers have known for decades that many Americans incorrectly think nicotine to be inherently deadly, but different studies have reached different conclusions about the prevalence of the misconception.
Now, new work from Rutgers Health explains why previous studies have disagreed and may suggest strategies for reducing misconceptions and tobacco-related harms.
The study in Nicotine & Tobacco Research presented survey takers with differently worded questions about the dangers of nicotine and found that such differences could push the percentage of people answering correctly from 10% to 80%.
"The headline is that there are widespread misperceptions about nicotine's role in health harms from smoking, and those misperceptions have been growing over time," said Andrea Villanti, deputy director of the Rutgers Institute for Nicotine and Tobacco Studies and lead author of the study. "Our work shows that you can also move those numbers by changing how you ask the question."
Nicotine is not harmless. The addictive substance can affect the heart and blood vessels. But authoritative reviews have not identified nicotine as a carcinogen in tobacco smoke, and the major health risks of cigarettes come from inhaling smoke filled with cancer-causing chemicals.
Noncombustible products such as nicotine replacement therapies and some smokeless products deliver nicotine with fewer toxic compounds than cigarettes because they don't burn tobacco.
Misperceptions about nicotine matter in part because they can discourage people who smoke from using tools that could help them quit. Earlier research by Villanti and others has found that people who wrongly believe nicotine causes cancer are less likely to use nicotine patches, gum or lozenges or to switch completely from cigarettes to less harmful products.
For the latest study, the Rutgers team embedded a randomized experiment in the Rutgers Omnibus Survey, a quarterly online survey that tracks tobacco and nicotine use. In August 2022, 2,526 adults aged 18 to 45 were randomly assigned to one of 10 questions about nicotine and cancer, drawn from national surveys and new items the researchers designed. After answering, each person typed a short explanation of how they had arrived at that answer.
When the team used wording similar to national surveys that ask whether nicotine is responsible for "most of the cancer caused by smoking," about 44% of respondents answered correctly. When the question was more direct - for example, "Nicotine is a cause of cancer" - that figure dropped to about 23% to 24%.
One novel statement, "Just the nicotine in cigarettes causes cancer," was answered as "correct" by 81% of respondents, but some people may have disagreed because they believed many chemicals in smoke cause cancer - including nicotine.
The open-ended explanations showed how the public tries to make sense of nicotine. Some respondents emphasized that exposure to smoke and other chemicals, not nicotine alone, causes cancer. Others said nicotine directly causes cancer, and a third group said nicotine causes cancer only because it keeps people addicted to smoking.
These misunderstandings have high stakes. The Food and Drug Administration has proposed a product standard that would require cigarette makers to reduce nicotine in cigarettes to nonaddictive levels, a move intended to make quitting easier and keep young people from getting hooked in the first place.
Villanti, who is also a professor at the Rutgers School of Public Health, said if people continue to see nicotine as the primary danger, they could read "low nicotine" on cigarette packs as "low risk" and keep smoking, even though the smoke would still be just as harmful.
"We did not come out of this with a single best question to use in future studies," Villanti said. "But if we want to design better messages and better policies around nicotine, we need to be clear on what people actually believe - and how much room there is to move them toward an accurate understanding of nicotine."
