Impact of Survey Item Wording and Response Options on Prevalence of Beliefs About Nicotine Causing Cancer: A...

Misperceptions of nicotine's role in health harms among US adults have increased. This study examined how survey item wording affects estimates of the misperception that nicotine itself causes cancer.

Two thousand five hundred twenty-six US adults aged 18-45 completed a randomized split-sample experiment through Cloud Research in August 2022. After receiving one of 10 existing and novel survey items about the role of nicotine in causing cancer, participants completed an open-ended question explaining their response. Analyses examined prevalence of beliefs by study condition and open-ended responses.

Overall, 36% of participants believed that nicotine does not cause cancer (coded as "correct"), but this varied by condition (10%-81%). Prevalence of this belief was similar when using magnitude-of-harm items from existing national surveys (HINTS, PATH; 44%) but lower with more direct wording (ie, "nicotine is a cause of cancer"; 23%). Changing response options (including/excluding don't know; true/false versus Likert scale) did not alter prevalence of a correct belief. Open-ended responses were distributed across four themes: (1) EXPOSURE to other chemicals or smoke cause cancer, not nicotine (n = 598, 23.7%), (2) Nicotine on its own DIRECTLY causes cancer (n = 705, 28.0%), (3) Nicotine only causes cancer by keeping people ADDICTED to tobacco (n = 796, 31.6%), and (4) Other (n = 419, 16.6%); study condition was associated with theme (p < .001).

Question wording influences the prevalence of agreement that nicotine itself causes cancer. Including "don't know," "probably yes," and "probably not" options may identify a broader group of people who could benefit from nicotine education.

Ensuring accuracy in estimating misperceptions about nicotine has implications for tobacco control in two important ways: first, these measures may identify the people or groups whose misperceptions may put them at greater risk for tobacco-related disease and death, and second, the prevalence of nicotine misperceptions and people affected may determine the prioritization and tailoring of interventions aimed at correcting misperceptions.