OBJECTIVES: Although evidence demonstrates that inhaling the smoke from combustion of cigarettes is responsible for the harm caused by smoking, the majority of U.S. adults who smoke inaccurately believe that nicotine causes the harm. These misperceptions may be a significant obstacle to adult smokers' motivations to switch to potentially reduced-harm, smoke-free products. This research quantified the population health impact associated with varying nicotine perceptions.

METHODS: We applied a previously validated agent-based model to the U.S. population. We developed a Base Case model using estimates of cigarette smoking initiation, cessation, and switching to exclusive smoke-free product use (i.e., use of e-cigarettes, smokeless tobacco and/or snus). We analyzed nationally representative data from the Population Assessment of Tobacco and Health (PATH) Study to estimate the overall rate of switching from smoking to smoke-free product use. We then stratified this rate based on responses to the question “Do you believe nicotine is the chemical that causes most of the cancer caused by smoking cigarettes?” (Four-item scale from “Definitely not” to “Definitely yes”). Nicotine perception scenarios were based on these stratified rates. The public health impact of nicotine perceptions was estimated as the difference in all-cause mortality between the Base Case and Nicotine Perception scenarios.

RESULTS: Switch rates aligned with those who responded “Definitely not” result in a net benefit of preventing nearly 800,000 premature deaths over an 85-year period. Conversely switch rates reflective of those who responded “Definitely yes” result in a net harm of nearly 300,000 additional premature deaths over the same period.

CONCLUSIONS: Accurate knowledge regarding the role of nicotine is associated with higher switching rates, translating into prevention of premature deaths. Limitations of predictive models must be considered when drawing inferences. Our findings suggest that promoting public education to correct nicotine misperceptions has potential to benefit population health.