Absolute and Relative Smokeless Tobacco Product Risk Perceptions: Developing and Validating New Measures that are Up-to-Snuff

Tobacco risk perceptions impact behavior. Our 2018 systematic review of tobacco risk perception measures found no measures of smokeless tobacco (ST) risk perceptions with demonstrated validity and complete consistency with tobacco researcher recommendations (e.g. specifying use frequency). This study develops such measures to assess seven specific risk perceptions of market-leading ST products: absolute health and addiction risks, health and addiction risks relative to cigarettes, pregnancy health risks relative to cigarettes, health risks relative to nicotine replacement therapy, and health risks relative to tobacco cessation. Methods and Results We fielded 64 items assessing risk perceptions associated with tobacco in an online survey experiment (N = 2754) that tested effects of exposing participants to a modified risk claim on a leading ST product. Through reliability and validity analyses, we reduced this to 35 items representing seven constructs. Exploratory factor analyses indicated single-factor solutions for all but two constructs: absolute health risk and health risk relative to cigarettes, which were each represented by two-factors (respiratory and oral risks). Participants perceived respiratory risks differently than oral risks: a modified risk claim reduced ST relative respiratory risk perceptions but increased ST perceived oral risks. Conclusions Absolute and relative risk perceptions were each represented by two factors that behaved differently, underscoring the utility of assessing respiratory and oral risk perceptions separately. These measures of seven risk perception constructs demonstrated some validity and can be used to assess perceptions of ST risk in future research, such as postmarket surveillance of tobacco products authorized for marketing by FDA. Implications This study develops and validates publicly available measures of seven smokeless tobacco risk perception constructs: absolute health and addiction risks, health and addiction risks relative to cigarettes, pregnancy health risks relative to cigarettes, health risks relative to nicotine replacement therapy, and health risks relative to tobacco cessation. This study suggests that for both absolute and relative risk perceptions, risks of respiratory and oral health effects should be assessed separately, because these risk perceptions may be impacted differently by modified risk claims, and are differentially related to smokeless tobacco beliefs, use intentions, and current use.