Comparative Risk Perceptions of Alternative Nicotine Products Among People Who Smoke Cigarettes and Dual Products: Findings From the 2024 ITC Korea Survey

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Objective: Heated tobacco products (HTPs) and e-cigarettes (ECs) have rapidly expanded in the Republic of Korea. This study aimed to examine differences in comparative risk perceptions of HTPs and ECs relative to cigarettes among Korean adults and to identify factors associated with these perceptions. Methods: Data were drawn from the KRA4-Cohort 3 dataset of the nationally representative International Tobacco Control Korea Survey and were analyzed for respondents who currently used cigarettes, HTPs, or ECs. Two ordinal outcomes measured perceived comparative harm of HTPs and ECs relative to cigarettes. Multivariable Bayesian ordinal logistic regression models were fitted, and robustness was assessed using Bayesian Metropolis-Hastings and frequentist sensitivity analyses. Results: Compared with cigarette-only users, respondents who used both cigarettes and HTPs had lower odds of perceiving HTPs as equally or more harmful than cigarettes (adjusted odds ratio [aOR], 0.43; 95% credible interval [CrI], 0.36 to 0.50). Similarly, respondents who used both cigarettes and ECs had lower odds of perceiving ECs as equally or more harmful than cigarettes (aOR, 0.31; 95% CrI, 0.19 to 0.47). Adults aged 40-59 years had higher odds of perceiving both products as equally or more harmful than cigarettes (HTPs: aOR, 1.35; 95% CrI, 1.12 to 1.61; ECs: aOR, 1.42; 95% CrI, 1.18 to 1.73). Noticing tobacco advertising was associated with lower perceived harm. Findings were consistent across the 3 analytic approaches. Conclusions: Lower perceived harm of HTPs and ECs relative to cigarettes was common among Korean adults who smoked cigarettes, especially among dual-product users and those exposed to marketing. Stronger advertising regulation, standardized warnings, and comparative risk education are needed to address misperceptions about relative harmfulness and support cessation.

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