Beliefs about the relative harmfulness of electronic cigarettes compared with cigarettes among adults: findings from the ITC Israel Survey

Introduction Electronic cigarettes (ECs) have gained substantial popularity, yet misperceptions that ECs are equally or more harmful than combustible cigarettes are increasing. In Israel, where smoking prevalence remains high, particularly among lower socioeconomic groups and the Arab minority, population-level perceptions of EC harms are unknown. Methods Data were drawn from the International Tobacco Control (ITC) Israel Survey, a nationally representative survey of 659 adults conducted in March-June 2022. The study assessed perceptions of (1) the relative harmfulness of ECs compared with cigarettes, (2) the health effects of completely switching from cigarettes to ECs, and (3) the relative harm of EC vapour compared with cigarette smoke. Associations with sociodemographic characteristics and smoking status were examined. Results Overall, 29.3% of Israeli adults perceived ECs as less harmful than cigarettes, 51.5% as equally or more harmful, and 19.0% did not know. Smokers were more likely to believe that ECs were more harmful. Regarding completely switching, 30.0% believed health would improve, 17.8% worsen, 33.2% no effect, and 19.1% did not know. Arab respondents were more likely than Jewish respondents to perceive ECs as equally or more harmful than cigarettes. Younger adults ('40 years) were less likely than older adults to perceive switching to ECs as harmful. Conclusions Misperceptions about the relative harms of ECs are widespread among Israeli adults, including those who smoke, suggesting a failure of risk communication. Clear, evidence-based communication is needed to support informed decision-making among adult smokers, while maintaining strong protections against EC uptake among non-smoking youth.