The global prevalence of tobacco products has led to increasing rates of smoking-related diseases and deaths, making smoking cessation a crucial priority in the field of public health [
1]. The current landscape of tobacco use presents new challenges and opportunities. For instance, there has been a decrease in the number of cigarette users who are addicted to traditional cigarettes in this decade [
2]. Additionally, the availability of various alternative nicotine-delivery devices allows adults who smoke a range of options [
3].
The e-cigarette, or electronic nicotine delivery system (ENDS), is a new nicotine product [
4‐
6] that has become increasingly popular in the United States [
7,
8]. Initially marketed as smoking cessation products [
9], the effectiveness of e-cigarettes in aiding smoking cessation remains a topic of controversy [
10,
11]. Specifically, the dual use of cigarettes and e-cigarettes is an emerging phenomenon [
12], as substantiated by multiple studies [
13‐
16], that has been found to contribute to the prolonged use of combustible tobacco products. Moreover, most studies [
17,
18] indicate that current cigarette users are more inclined to engage in the use of e-cigarettes, which raises our concerns regarding the factors contributing to this transition.
Health-related social media are presented on social media platforms for various health-related purposes and involve the active participation of health institutions, professionals, and the public in leveraging digital channels to address health issues and promote well-being [
19]. Unprecedented growth in social media use has revolutionized the way that individuals access and share health-related information, which may offer a unique avenue for users to engage with a broader range of health topics, including smoking cessation [
20,
21].
Notably, there are apparent differences between general social media use and specific health-related social media use (HSMU). First, much health-related content is generated by public health government or experts’ social media accounts; these accounts convey a greater sense of professionalism and credibility than general social media accounts [
22]. Second, users’ search intentions for health-related social media are usually more focused on their health concerns [
23]. These disparities in content and user intentions underscore the heightened importance of health-related social media platforms within the realm of public health, similar to the realm of tobacco control.
E-cigarettes have often been portrayed on social media platforms as a means to relieve cravings or reduce cigarette consumption among those attempting to quit smoking [
24,
25]. However, the literature addressing the effects of HSMU on cigarette and e-cigarette use (ECU) remains limited [
26]. Further exploration is warranted to understand the mechanisms underlying the relationship between HSMU and e-cigarette consumption among current cigarette users to bridge this research gap. Then we can come out with our first research question:
Theory framework
In our research context, we anchor this study to Harm Reduction Theory (HRT). HRT acknowledges the persistence of unhealthy behaviors and centers on minimizing their associated risks rather than pursuing complete elimination, resulting in a focus on reducing harm rather than imposing immediate cessation of these behaviors [
27]. Originally devised to address the multifaceted harms associated with drug abuse [
28‐
30], HRT has evolved to encompass broader health concerns, including alcohol abuse [
31] and tobacco use [
32]. At its core, this theory underscores the importance of balancing risks and benefits, recognizing that absolute cessation may not always be immediately achievable. In this context, e-cigarettes, while not without risks, can be viewed as a harm reduction strategy compared to traditional cigarettes, aligning with the core principles of HRT.
Anti-tobacco campaigns and advertisements are widely used to raise awareness of the risks associated with tobacco product use, with the aim of reducing smoking [
33]. Previous research suggests that, due to the limited resources of tobacco control programs, optimal effectiveness can be achieved by focusing efforts on specific objectives, such as promoting smoking cessation among adult cigarette users [
34‐
36]. Additionally, previous studies have demonstrated that anti-tobacco campaigns aimed at the general population are also more likely to impact adults who smoke cigarettes than nonsmokers [
34,
37].
With the advancement of the internet and social media platforms, online anti-tobacco messages have emerged and evolved, potentially amplifying their exposure among cigarette users. Studies have shown that cigarette users are more likely to encounter tobacco-related messages on social media, including both pro- and anti-tobacco messages [
38].
Furthermore, Ahadzadeh, Sharif [
23] underscored the propensity of health-related social media platforms to attract health-conscious individuals who use them for health purposes. Because the algorithmic mechanisms of social media platforms can contribute to the creation of “echo chambers” [
39], current cigarette users who engage with health-related social media content about smoking risk may be more inclined to encounter anti-tobacco messages. Consequently, they may have a greater likelihood of being exposed to anti-tobacco messages on the internet [
40], including social media, websites, and other online platforms.
Despite anti-tobacco messages generally aiming to discourage the use of all kinds of tobacco products, research shows that the majority of studies on the effects of anti-tobacco messages primarily concentrate on cigarettes [
41]. This research preference may suggest a predominant focus on anti-cigarette messaging in both online and offline contexts [
40]. Additionally, some stakeholders associated with e-cigarettes may seek to promote them for smoking cessation while downplaying their harmful effects on social media [
42,
43]. This status quo could lead current cigarette users to perceive traditional cigarettes as more harmful than e-cigarettes.
To our knowledge, the influence of online anti-tobacco messages on current cigarette users transitioning to ECU remains an underexplored area in current research. A pioneering study [
38] investigated the association between self-reported engagement with anti-tobacco messages on social media and subsequent ECU. However, the findings showed no significant correlation between such engagement and ECU.
In the early days of e-cigarettes, public belief that e-cigarettes are healthier than traditional cigarettes was expected, and people were given reasons to use e-cigarettes to quit smoking [
44]. However, as studies on e-cigarettes continue to advance, there has been growing concern about the potential harm of e-cigarettes and their impact on public health [
45‐
47]. Moreover, the emergence of two critical public health concerns, namely Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) and coronavirus disease 2019 (COVID-19), in the United States has made an increasing number of people concerned about the harm caused by e-cigarettes [
48,
49].
Harm perception might have moderating effects on current cigarette users’ decisions regarding ECU. Multiple studies have demonstrated that those who perceive e-cigarettes as less harmful than traditional cigarettes are more likely to use e-cigarettes [
50‐
53]. The difference in the perceived harm of e-cigarettes across population samples (e.g., daily users, non daily users, and triers) has been proven in previous studies [
54]. These findings suggest that current cigarette users with a heightened sense of harm associated with e-cigarettes may be less likely to use e-cigarettes.
Based on the literature reviews presented above, the following hypotheses and research questions emerge: