Communicating the Nicotine and Tobacco Risk Continuum: A Scoping Review and Framework for Future Messaging

The U.S. FDA acknowledges that commercial nicotine and tobacco products (NTPs) exist along a continuum of risk (COR), yet strategies to effectively communicate this concept remain underexamined. This scoping review synthesizes peer-reviewed studies on COR messaging across NTPs to identify promising practices and research gaps.

Following PRISMA-ScR guidelines, we searched PubMed, CINAHL, PsycINFO, and Scopus for English-language articles (2014-2024) that empirically tested comparative or modified risk messages across NTPs. Two authors independently screened and extracted data on the conceptualization, operationalization, and effectiveness of COR messaging. We used the Message Impact Framework (MIF) to categorize message effectiveness by message receptivity, precursors to behavior, and behavioral outcomes.

Of 531 articles identified, 50 met the inclusion criteria. COR messaging was conceptualized and operationalized inconsistently across studies, with most focusing on binary comparisons (e.g., e-cigarettes/snus vs. cigarettes) rather than communicating the broader COR across multiple NTPs. The operationalization of COR messaging differed in message content (e.g., specific vs. general harm, reduced exposure vs. risk), feature (e.g., audience targeting, message source, numeric information), and delivery (e.g., placement, format). COR messages generally increased the accuracy of risk perceptions of lower-risk NTPs, though effectiveness varied.

This scoping review identified practical tactics and key challenges for COR messaging across NTPs, including heterogeneous design, confusion about "complete switching," and unintended "halo effects." We propose a definition of COR messaging and a framework to address the need for a standardized conceptualization and more comprehensive evaluation of its effectiveness in future research.