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RESEARCH ARTICLE
How did beliefs and perceptions about e-
cigarettes change after national news
coverage of the EVALI outbreak?
Jennifer C. MorganID*, Nathan Silver, Joseph N. Cappella
Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, United States of
America
Abstract
Introduction
Exposure to media content can shape public opinions about tobacco. In early September
2019, the outbreak of e-cigarette, or vaping, product use–associated lung injury (EVALI)
became headline news in the United States.
Methods
In August and September 2019, we conducted two cross-sectional online surveys with cur-
rent and former smokers assessing attitudes and beliefs about e-cigarettes. Study one (n =
865) was collected before the EVALI outbreak was widely covered and study two (n = 344)
was collected after the outbreak had become nation-wide news. We examined differences
in perceptions and beliefs between time points.
Results
E-cigarette harm perceptions increased between study one (mean = 2.67) and study two
(mean = 2.90, p < .05). Ever-users of e-cigarettes largely account for this change. Endorse-
ment of the belief that e-cigarettes were risky and more likely to cause lung damage com-
pared to cigarettes increased between studies (p < .05). Seventy eight percent of
participants at study two were aware of the vaping illness story. Being aware of the story
was associated with more endorsement of the belief that e-cigarettes were risky to use, but
not that using e-cigarettes would make the participant more likely to get damaged lungs.
Discussion
When the stories about the health and safety of tobacco products dominate the public infor-
mation environment, it presents an opportunity to change beliefs that are frequently targeted
by paid health campaigns. Changes in participant’s perceptions of e-cigarettes were associ-
ated with coverage of this large news story, underscoring the importance of working to
ensure that coverage is a scientifically accurate as possible.
PLOS ONE
PLOS ONE | https://doi.org/10.1371/journal.pone.0250908 April 30, 2021 1 / 14
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Citation: Morgan JC, Silver N, Cappella JN (2021)
How did beliefs and perceptions about e-cigarettes
change after national news coverage of the EVALI
outbreak? PLoS ONE 16(4): e0250908. https://doi.
org/10.1371/journal.pone.0250908
Editor: Michael Cummings, Medical University of
South Carolina, UNITED STATES
Received: September 25, 2020
Accepted: April 7, 2021
Published: April 30, 2021
Copyright: © 2021 Morgan et al. This is an open
access article distributed under the terms of the
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting
Information files.
Funding: Research reported in this paper was
supported by grant number U54 CA229973-01
from the National Cancer Institute and the FDA
Center for Tobacco Products (CTP). The content is
solely the responsibility of the authors and does
not necessarily represent the official views of the
NIH or the Food and Drug Administration. The
funders had no role in study design, data collection
Introduction
Electronic cigarettes, or vaping devices, produce an inhalable aerosol that usually contains nic-
otine, flavorings and other chemicals [1]. While the name “vaping” conjures the idea of harm-
less water vaper, the aerosol can expose users to heavy metals, volatile organic compounds and
other harmful ingredients know to have adverse health effects [2, 3]. In August 2019, Wiscon-
sin reported the first cluster of lung injuries to the Centers for Disease Control and Prevention
(CDC) [4]. The CDC worked with federal and state partners to address a multistate outbreak
of e-cigarette, or vaping, product use–associated lung injury (EVALI) [5]. A total of 2807 cases
of EVALI and 68 deaths had been reported to the CDC as of February, 2020 [5]. All patients
with EVALI have reported using vaping products. Nationally, most of these patients reported
using Tetrahydrocannabinol (THC)-containing products, but a minority reported exclusive
use of nicotine-containing products [5, 6].
Beginning in September 2019, news surrounding a vaping illness simultaneously prompted
restrictions and bans by local governments because of the questions about the safety of elec-
tronic nicotine delivery systems [6], and a defense of e-cigarettes by industry representatives
claiming that it was bootleg, cannabis-based cartridges that were leading to the injuries, and
not the nicotine-based cartridges that were sold legally [7]. Extensive coverage of EVALI was
likely effective in spotlighting the issue of e-cigarettes safety [8]. However, conflicting informa-
tion about the cause, and uncertainty about the cause when the news first broke [7–9], may
have limited the ability of the news to perform one of its functions and accurately inform peo-
ple about the actual and potential dangers [10–12].
The U.S. Food and Drug Administration (FDA) acknowledges that in comparison to com-
bustible cigarettes, which kill up to half of life-long smokers, e-cigarettes lie on the lower end
of a continuum of risk [13–15]. Yet, many smokers in the U.S. believe e-cigarettes are at least
as harmful to health as combustible cigarettes [16]. This may dissuade them from switching to
e-cigarettes and, thus, have a detrimental impact on population health. Widespread news cov-
erage of the EVALI outbreak may have increased confusion about the relative harms of these
products.
Media scholars posit that mass media serves four core functions: (a) information distribu-
tion, reporting events to the public; (b) interpretation, providing the context for and meaning
of issues and events; (c) socialization, cultivating community values, beliefs, and norms; and
(d) entertainment, providing diversion and escape from everyday life [17, 18]. Though news
media can affect policy and behavior change through providing a source of health and science
information [19–21], the effect of that information is not consistent. Thus, we sought to exam-
ine whether the initial widespread news coverage of EVALI changed perceptions and beliefs
about e-cigarettes, especially beliefs about the harms and risks of e-cigarettes among users.
Methods
Overview
This paper combines the results from two studies to provide data on our research questions.
Study one was conducted to assess awareness, harm perceptions and beliefs about three differ-
ent tobacco products: e-cigarettes, snus, and heat-not-burn tobacco, that have the potential to
be authorized as modified risk tobacco products (MRTPs) [22]. This study was completed
before EVALI news coverage. Within a week of concluding data gathering for study one, news
coverage of EVALI increased substantially. A month before our first study (July 28th to Aug
28th), a ProQuest search in the recent news database using the terms “vaping illness” OR “e-
cigarette illness” OR “mysterious lung disease” OR “lung illness” yields 0 news stories. From
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and analysis, decision to publish, or preparation of
the manuscript.
Competing interests: The authors have no
conflicts of interest to disclose.
Aug 29th- Sept 29th, the same search yields 297 entries, including a front-page New York
Times article (Fig 1). Given this opportunity for a natural experiment, we went back into the
field with the same measures in order to assess how perceptions and beliefs about e-cigarettes
had changed after the news coverage (study two). Like study one, study two survey also
assessed awareness, harm perceptions, and beliefs about e-cigarettes. We added items to study
two survey that assessed awareness of the news story. Study two was conducted before the
“mysterious vaping illness” was given the name EVALI, and before THC or vitamin E acetate
was widely accepted as the cause.
Participants
Study one. We recruited 865 adult current and former smokers to complete an online sur-
vey about MRTP beliefs through Dynata from August 27–28, 2019. Using established defini-
tions of smoking status [23], participants were considered current smokers if they had smoked
at least 100 cigarettes in their lifetime and currently smoke every day or some days, and former
smokers if they had smoked at least 100 cigarettes in their lifetime, and currently did not
smoke at all. Additionally, participants could not have participated in more than two online
surveys about cigarette smoking or other tobacco products in the last three months. Partici-
pants included 450 men and 414 women, with a mean age of 47.5 years. A little more than half
of the participants were current smokers or ever-users of e-cigarettes. Participants had similar
demographics to a national sample of smokers [23], as they were diverse in race, education,
and income, though our sample was slightly more educated than the population of US smok-
ers. The purpose of study one was to understand what people believe about MRTPs, and how
information they get from brands might influences those beliefs. The sample size for study one
allows for comparisons between the three products within subgroups of smoker and non-
smoker, and between groups with differing experiences with MTRPs.
Study two. Using Dynata and the same inclusion and exclusion criteria, we recruited an
independent sample of 344 adult current and former smokers from September 27–29, 2019.
Participants included 163 men and 181 women, with a mean age of 46.7 years. Participant
characteristics were statistically similar between the two studies (Table 1). The sample size for
study was chosen to allow for meaningful comparisons between subgroups of e-cigarette users
and between time periods.
Procedures
Study one. Eligible participants answered demographic survey questions and information
about their current smoking behavior. Study one’s purpose was to understand what people
believe about MRTPs, and how information they get from brands might influences those
beliefs. Participants read a paragraph describing the potential for the FDA to authorize MRTPs
and a brief description of MRTPs. Participants were randomly assigned to either the control
condition, in which they read a generic description about e-cigarettes, snus, and heat-not-
burn tobacco, presented in random order; or to the corporate social responsibility condition,
in which they read the generic description, plus a corporate responsibility statement crafted
using press releases and text from IQOS, General Snus, or JUUL’s website respectively. There
were no differences between the conditions, so the conditions were collapsed in subsequent
analyses.
After reading descriptions of MRTPs, and a description of the products, participants
answered questions about awareness, harm perceptions, use, and susceptibility to each of the
products. Then the survey assessed 15 different beliefs for the three products. The belief
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questions were worded using three different variations and participants were randomly
assigned one wording variation per product using a Latin-square design.
Participants read a consent form that provided the approximate time it would take to com-
plete the survey, emphasized that their participation was voluntary, and supplied the contact
information for the study PIs and the Institutional Review Board. After reading through the con-
sent form, they were instructed to click through to the next page. The consent form advised those
who did not wished to participate to close their internet browsers. The University of Pennsylvania
institutional review board approved the consent process, study procedures, and study materials.
Study two. Study two was designed to take advantage of the fact that study one had
occurred just prior to a large national news story about one of the products. Participants in
study two completed a very similar survey. The survey was identical up until the Latin-square
design assessment of the 15 beliefs. Study two only assessed beliefs about e-cigarettes. Measures
assessing awareness of health news stories from the previous two months were added after the
belief assessment in study two.
Measures in study one and study two
E-cigarette use. Participants who answered that they had heard of e-cigarettes before the
time of the survey indicated whether they had ever used an e-cigarette or vaping device, even
Fig 1. EVALI news coverage in Fall, 2019.
https://doi.org/10.1371/journal.pone.0250908.g001
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one or two times. Participants who answered yes responded with how many of the last 30 days
they had used the device(s). Participants who were unaware of e-cigarettes, or who had never
used an e-cigarette were considered never users. Participants who answered that they had used
an e-cigarette but reported that they had not used one in the last 30 days were considered for-
mer users. Those who had used an e-cigarette at least once in the last 30 days were considered
current users of e-cigarettes. Because the participants were all current or former smokers, the
former and current users have experience with both cigarettes and e-cigarettes.
Harm perceptions. Participants indicated how harmful they thought e-cigarettes were to
their health on a scale of not at all harmful (1), to extremely harmful (4). This measure was
adapted from the Population Assessment of Tobacco and Health survey [24].
E-cigarette beliefs. The surveys assessed 15 different beliefs about e-cigarettes: being
risky, having long term health benefits, causing lung damage, tasting good, feeling harsh, being
odorless, being easy to use, looking cool, making second hand smoke, not being addictive,
Table 1. Number and percentage of participants with various demographic characteristics.
Characteristic Study 1 (n = 865) Study 2 (n = 344)
n (%) n (%)
Mean age (SD) 47.5 (17.6) 46.7 (16.4)
Gender
Male 450 (52) 163 (47)
Female 414 (48) 181 (53)
Hispanic 59 (7) 37 (11)�
Race
White 732 (85) 296 (86)
Black or African American 81 (9) 18 (5)
Asian 14 (2) 1 (.3)
American Indian, Alaska Native, or Native Hawaiian 34 (4) 20 (6)
Multiple races selected – 9(3)
Education
High school or less 283 (33) 134 (39)
Some college 201 (23) 64 (19)
College or higher 380 (44) 146 (42)
Income
Less than $25,000 187 (22) 79 (23)
Between $25,000 and $49,999 213 (25) 83 (24)
Between $50,000 and $74,999 164 (19) 66 (19)
Between $75,000 and $99,999 126 (15) 53 (15)
Between $100,000 and $149,999 117 (14) 35 (10)
$150,000 or more 55 (6) 27 (8)
Smoking status
Current smoker 463 (54) 201 (58)
Former smoker 402 (46) 143 (42)
E-cigarette user status
Current 284 (33) 116 (34)
Former 168 (19) 68 (20)
Never 412 (48) 160(47)
Note. Pearson X2 test
�p< .05. Missing data ranged from 0% to .5%
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containing nicotine, helping smokers quit, untrustworthy science about the product, appealing
to kids, and being expensive (Appendix A). The decision to focus on these beliefs was based on
prior qualitative research, surveys on salient beliefs, and examining the MRTP applications
and materials made publicly available [22, 25–34]. The 5-point response scale ranged from
strongly disagree (1) to strongly agree (5). The survey assessed these beliefs using three word-
ing variations in study one: a comparison to cigarettes, a self-referent, and an absolute state-
ment. Spearman ranked correlations of the beliefs between the absolute wording belief
ranking and the self-referent wording ranking was very high (ρ (rho) = .98, p< .001) indicat-
ing that participants did not meaningfully differentiate the two wording variations [35]. Con-
sequently, in study two, only the comparison and self-referent wording variations were used (ρ (rho) = .63, p< .05).
Measure in study two
Awareness of EVALI story. The survey presented the participants with five one-sentence
descriptions of news stories about health that had been run in the past two months. These five
stories were presented in a random order and included “Several patients around the country
have died because of a mysterious lung ailment tied to vaping.” Other story options were
about cardiovascular health of dog owners, allergic reactions because of tattoos, pharmaceuti-
cal companies facing fines because of their ties to opioids, and the percent of American youth
who had tried vaping. Participants indicated whether they had heard of, read, or seen the story
(coded as 1) or not (coded as 0), or if they didn’t know (coded as 0).
Statistical analysis
The research questions motivating the analysis were:
1. Did harm perceptions and beliefs about e-cigarettes change between study one and study
two, particularly for beliefs about health harms or benefits?
2. Did changes between study one and study two differ by e-cigarette user status?
We conducted t-tests adjusted for unequal sample sizes and X2 in STATA 14.0 [36] to
examine differences in harm perceptions between time points. To prevent multiple compari-
sons from increasing the false positive rates, we conducted a MANOVA for beliefs, followed
by post hoc analysis when the MANOVA indicated significant differences between study one
and study two. The University of Pennsylvania institutional review board approved the
procedures.
Results
News coverage and perceived harm
Between study one and study two, during which news coverage of EVALI was intense relative
to baseline (Fig 1), the information circulating in the public information environment was
associated with an increase in e-cigarette harm perceptions (mean = 2.67 (sd = .90) to m = 2.90
(.97), p< .001). This change was largely driven by ever-users of e-cigarettes, specifically for-
mer-users (m = 2.61 (.81) to m = 2.99(.94,) p< .01). Never users’ perceptions trended in the
same with a smaller and non-significant difference between time 1 and 2 (m = 2.98(.88) to
m = 3.14(.92), p = .051; Table 2).
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Fifteen beliefs about e-cigarettes
Between study one and study two some important beliefs did not change significantly after
intense news coverage of EVALI; the risk of e-cigarette use, lung damage and long-term health
benefits. Some social beliefs about e-cigarettes being easy to use, cool, and appealing to kids
decreased between study one and two by .2 to .4 points (p< .05; Fig 2). When the comparison to cigarettes was invoked, the belief that e-cigarettes were riskier, more likely to cause lung
damage, and cooler increased by .3 to .4 points between study one and two (p< .05). Increased
information in the public information environment about e-cigs is affecting beliefs about ciga-
rettes, but only when a comparison to cigarettes is invoked.
A MANOVA did not indicate significant differences between study one and study two for
the set of 15 beliefs for current users, or when a comparison to cigarettes was invoked. A
MANOVA indicated significant differences between study one and study two for the set of 15
beliefs for never and former users, therefore we conducted post hoc t-tests to examine which
of the 15 beliefs changed significantly between study one and study two. For current users, this
indicates that there was no significant difference in the endorsement of beliefs about e-ciga-
rettes being risky, having long term health benefits, or causing lung damage between study one
and study two. In comparison, never user’s beliefs about e-cigarettes causing lung damage,
being risky to use, and feeling harsh, increased after EVALI news coverage (p< .05; Table 3).
The group most at-risk (current users) did not accept the lung damage risk assessment, while
the group at lowest risk (never users) did. Information in the public information environment
about e-cigarettes is not affecting the at-risk current user group.
Awareness of coverage
Seventy eight percent of participants in study two were aware of the EVALI story, the highest
of any of the stories we asked about. In comparison, 22% of people had heard about allergic
reactions because of tattoos, 36% about the cardiovascular health of dog owners, 56% about
the percent of American youth who had tried vaping, and 57% about pharmaceutical compa-
nies facing fines because of their ties to opioids. Those aware of the EVALI story were more
likely to endorse the belief that e-cigarettes were risky compared to cigarettes (munaware = 3.05,
maware = 3.43, p = .03); a similar pattern occurred for the parallel question focused on one’s
own risk (munaware = 3.70, maware = 4.05, p = .07; Fig 3). Awareness was not related to the belief
that e-cigarettes would cause lung damage.
Sub-groups of aware-unaware by user status are small and unstable but potentially instruc-
tive about the impact of the information circulating in the public environment. Due to the
small numbers, we compared current users to non-users (both former users and never users)
in sub-group analysis. For non-users, awareness of the story was associated with endorsement
Table 2. E-cigarette harm perception changes between study one and two for never, former, and current users of
e-cigarettes.
Study one Mean (SD) Study two Mean (SD) Effect size Hedges’ g
All participants 2.67 (.90) 2.90 (.97)� -.25
Never user 2.98 (.88) 3.14 (.92) -.18
Former user 2.61(.81) 2.99 (.94)� -.43
Current user 2.27 (.81) 2.52 (.94)� -.29
Note: E-cigarette health harm perceptions were measured on a scale of not at all harmful (coded as 1) to extremely
harmful (coded as 4).
�p < .05
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of the belief that using e-cigarettes was risky (munaware = 3.95, maware = 4.4, p = .06, Hedges’ g
effect size = -.59; Table 4). There was no difference in endorsement between aware and
unaware current users (munaware = 3.33, maware = 3.30, ns, effect size = .03).
Fig 2. E-cigarette belief changes from study one to study two. A MANOVA indicated significant differences in beliefs from study one and study two. Bold arrows
indicate the beliefs that were significantly different between study one and study two (p< .05). The grey bar separates the wording variations.
https://doi.org/10.1371/journal.pone.0250908.g002
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For these same subgroups, when a comparison to cigarettes is primed, unaware non-users
exhibited less acceptance of e-cigarette risk compared to cigarettes than aware never users
(munaware = 2.96, maware = 3.61, p< .01; Hedges’ g effect size = -.69; Table 4). For long-term
health benefits of e-cigarettes compared to cigarettes, lower endorsement occurred among the
aware compared to the unaware (munaware = 3.00, maware = 2.27, p< .01, Hedges’ g effect size =
-.55). Story awareness among current users of e-cigarettes exhibited no differences or trends
Table 3. E-cigarette belief change differences over time by user status.
Self-referent Comparison
Never Former Current Never Former Current
Study 1 Study 2 Study 1 Study 2 Study 1 Study 2 Study 1 Study 2 Study 1 Study 2 Study 1 Study 2
Risky 4.08 4.36� 3.97 4.24 3.57 3.31 3.24 3.49 3.11 3.35 2.58 3.12
Lung damage 4.03 4.29� 3.92 4.00 3.61 3.48 3.27 3.58 2.98 3.26 2.87 3.30
Long-term health benefits 2.36 2.53 2.50 2.78 2.89 3.07 2.44 2.31 2.32 2.84 2.73 3.18
Cool 2.07 1.70� 2.21 1.57� 2.93 2.78 2.36 2.60 2.30 3.06 3.10 3.44
Untrustworthy sci 3.68 3.86 3.53 3.97� 3.24 3.28 3.76 3.54 3.25 3.58 3.04 3.25
Feel harsh 3.27 3.55� 3.16 3.32 2.94 2.88 3.09 3.06 2.69 2.71 2.68 3.21
Easy 3.36 3.01� 3.71 3.57 3.91 3.86 2.88 2.99 3.04 3.42 3.68 3.84
Taste good 2.70 2.57 3.14 2.81 3.61 3.83 2.91 2.85 3.00 3.48 3.80 3.75
No second-hand smoke 2.51 2.42 2.95 2.49 3.12 3.41 2.94 2.95 3.25 3.39 3.67 3.60
Odorless 2.53 2.56 2.70 2.62 2.91 3.29 2.72 2.72 2.58 2.74 3.17 3.53
Nicotine 3.95 3.96 4.16 4.24 3.93 3.86 3.06 3.13 2.96 2.68 2.81 3.14
Quit aid 2.28 2.18 2.59 2.16 3.34 3.45 2.53 2.34 2.63 2.84 3.52 3.53
Not addictive 2.12 1.90 1.98 1.73 2.53 2.69 2.04 2.22 1.91 2.16 2.93 3.14
Kid appeal 3.81 3.61 3.53 3.22 3.58 3.09 3.63 3.77 3.36 3.65 3.62 3.79
Expensive 3.88 4.00 3.73 3.54 3.43 3.36 3.43 3.40 3.20 3.52 3.13 3.53
Note. E-cigarette beliefs were measured on a scale of strongly disagree (coded as 1) to strongly agree (coded as 5). The MANOVA did not indicate significant differences
between study one and study two for the set of 15 beliefs for current users, or anyone who answered the comparison wording variation (greyed out cells), therefore we
did not conduct post-hoc analyses examining differences for individual beliefs in those sub groups. Significant differences in post hoc t-tests on individual beliefs (white
cells) are indicated with an � indicating a p < .05.
https://doi.org/10.1371/journal.pone.0250908.t003
Fig 3. Mean belief endorsement differences in study two among participants who were unaware of the EVALI
news compared to those who were aware. Number of unaware participants = 76 (n = 37 for self-referent wording and
n = 39 for comparison wording). Number of aware participants = 276 (n = 135 for self-referent and n = 132 for
comparison wording). Welch t-test implemented to account for unequal sample sizes, �p< .05 ^p = .07.
https://doi.org/10.1371/journal.pone.0250908.g003
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approaching significance for beliefs that e-cigarettes are riskier, cause lung damage, or have
long-term health benefits compared to regular cigarettes.
Discussion
Study two took place before EVALI had been officially named, and before confirmation of
THC and vitamin E acetate as the likely causes of EVALI. Some news stories mention these as
potential causes in the coverage of the “mysterious vaping illness.” In a public information
environment that was working perfectly in service to public health at the time of study two, we
would expect EVALI news to cause an increase in harm perceptions, an increase in the belief
that e-cigarettes were risky and caused lung damage, and a decrease in the beliefs that e-ciga-
rettes had long-term benefits. Our study did not find such neat and tidy results, leading us to
examine why the information environment led to some of the expected and hoped for out-
comes, but not all. This study did find that attitudes and beliefs about e-cigarettes changed
after EVALI news became a well-known story. But rather than perceptions and beliefs moving
systematically within the population, there were differences in how much the beliefs changed
over time between e-cigarette never, former, and current users and when evaluating e-ciga-
rettes on their own, or in comparison to cigarettes. There were no beliefs that changed signifi-
cantly for all user groups and when referencing cigarettes and not.
From a public health perspective, we would hope that the EVALI news stories in the infor-
mation environment would reach and move the most at-risk population, in this case, the cur-
rent users of e-cigarettes. While harm perceptions about e-cigarettes increased overall after the
EVALI coverage, the change among never users was small. Importantly, never users already
had higher perceptions of harm, and the perceptions of harm among current users after
Table 4. Mean belief endorsement about e-cigarettes among participants aware and unaware of the EVALI news story by user status and wording variation.
Self-referent Comparison
All participants Aware of EVALI
news (n = 135)
Unaware of EVALI
news (n = 37)
Hedges’ g
effect size
Aware of EVALI
news (n = 132)
Unaware of EVALI
news (n = 39)
Hedges’ g
effect size
Risky 4.05 3.70^ -.36 3.43 3.05� -.35
Causes lung
damage
4.02 3.70 -.34 3.46 3.30 -.14
Long-term
health benefits
2.76 2.77 .01 2.59 3.02^ .32
Current users Aware (n = 43) Unaware (n = 15) Aware (n = 46) Unaware (n = 11)
Risky 3.30 3.33 .03 3.09 3.27 .14
Causes lung
damage
3.53 3.33 -.22 3.26 3.45 .16
Long-term
health benefits
3.16 2.8 -.32 3.19 3.09 -.08
Non-users (never and
former users)
Aware (n = 92) Unaware (n = 22) Aware (n = 86) Unaware (n = 28)
Risky 4.41 3.95^ -.59 3.61 2.96�� -.69
Causes lung
damage
4.25 3.95 -.35 3.57 3.25 -.31
Long-term
health benefits
2.57 2.76 .12 2.27 3.00�� .55
Note: E-cigarette beliefs were measured on a scale of strongly disagree (coded as 1) to strongly agree (coded as 5).
^p < .1
�p < .05
��p < .01.
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EVALI are still lower than never users and former users before the news coverage. While over-
all harm perceptions increased for current users, their beliefs about lung damage, risk, and
long-term health benefits of e-cigarettes did not change. The fact that there are differences
between never, former, and current users is consistent with research demonstrating the role of
involvement on message processing and attitude change [37]. Because current users have
more of a personal interest in the safety of e-cigarettes than never users, they are likely more
attentive to the information, and as a result are affected in different ways.
These data suggest that contrasting information processing motivations between groups
with different experiences using e-cigarettes moderated the effects of a prominent news event
on beliefs about the risks and benefits of vaping. That current users’ harm perceptions
increased following the EVALI news, suggests that safety concerns are likely a key difference
between the groups. For never users, the news of EVALI validated their previous behavior,
whereas it forced current users to reconcile their behavior with information that it is harmful.
It is instructive to note that different beliefs changed when the comparison to regular ciga- rettes was primed. While it is expected that public information environment after EVALI
would increase the beliefs about lung damage and risk, it is perplexing that those beliefs only
increased when in comparison to regular cigarettes. This may be a result of the larger news
narrative around e-cigarettes. The EVALI story and news concerning e-cigarettes in general
has focused extensively on their popularity with young people [6], while e-cigarette industry
marketing has focused on the benefits of e-cigarettes in comparison to cigarettes [38]. Thus,
smokers are evaluating EVALI in light of the larger news context. EVALI may make e-ciga-
rettes less appealing to use and have seemingly fewer benefits and more risks compared to
cigarettes.
Changes in participant’s perceptions of e-cigarettes were associated with awareness of the
coverage of this prominent news story, underscoring the importance of working to ensure that
coverage is a scientifically accurate as possible. Changing beliefs and perceptions after news
coverage is consistent with other news topics [21, 39–41]. It is particularly important to use
these news events that capture the public’s attention to provide accurate and not misleading
information. A morning consult poll conducted in mid-September indicated that 34% of
adults believed that the lung disease deaths were related to marijuana and THC-containing
vapes, while 58% percent said nicotine e-cigarettes such as Juul were to blame [42]. Given the
evolving nature of the story in the time leading to study two, which news reports were seen by
the participants may have been important in how beliefs and harm perceptions were changed.
However individual news exposure and awareness of specific news stories were not measured
in this study.
One of the limitations of this study is that it was not originally designed to capture changes
in the beliefs about e-cigarettes in reaction to the public news environment. Therefore, we do
not have data in study one about news consumption, exposure, or awareness, nor do we have
information about whether users in either study used THC in their e-cigarettes in addition to
tobacco. Cases of EVALI varied by state, and while awareness of the EVALI story was very
high compared to other news stories, some of the differences in awareness may be due to loca-
tion of the participants, which we did not measure. Because the first study’s aim was to capture
beliefs about MRTPs among former and current smokers, we do not have e-cigarette users
who have never used cigarettes in our sample. We did not anticipate conducting study two
while we were planning and conducting study one. As such, we had not designed study one to
allow for follow up with participants, the cross-sectional nature of these studies does not allow
us to infer causality. We believe that even with these limitations, the data provide insight into
how beliefs about tobacco products can change when there are major news events. We used
mainstream news coverage about the mysterious vaping illness as an indicator of the public
PLOS ONE E-cigarette belief and perception changes after EVALI news coverage
PLOS ONE | https://doi.org/10.1371/journal.pone.0250908 April 30, 2021 11 / 14
information environment. This was not intended to be a content analysis of mainstream or
social media news sources, which could tell us which stories were circulating and influential.
Instead, we can describe what beliefs and perceptions changed and did not change at the
height of EVALI new coverage.
When the public information environment is dominated by news stories about the health
and safety of tobacco products, it presents an opportunity to change beliefs that are frequently
targeted by paid health campaigns. The EVALI story, like any other, appears subject to selec-
tive perception [43]. Our experiences, attitudes, and existing beliefs shape how we view and
interpret news stories. A news story about a novel and complex issue like the safety of e-ciga-
rettes is particularly likely to evoke motivated reasoning processes [44], particularly among e-
cigarette users who have both a physical and emotional interest in the issue. Current users may
have read the stories more carefully or followed the nuances of the evolving story whereas
never users may not have followed the news as closely. However, as current users have a per-
sonal interest in whether e-cigarettes are safe, they are motivated to process information in
such a way that allows them to maintain that belief rather than change their behavior.
Supporting information
S1 Data.
(XLSX)
S2 Data.
(XLSX)
Author Contributions
Conceptualization: Jennifer C. Morgan, Joseph N. Cappella.
Data curation: Jennifer C. Morgan, Joseph N. Cappella.
Formal analysis: Jennifer C. Morgan.
Funding acquisition: Joseph N. Cappella.
Methodology: Joseph N. Cappella.
Project administration: Jennifer C. Morgan.
Resources: Joseph N. Cappella.
Supervision: Joseph N. Cappella.
Writing – original draft: Jennifer C. Morgan.
Writing – review & editing: Jennifer C. Morgan, Nathan Silver, Joseph N. Cappella.
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