Compliance With FDA Nicotine Warning Statement Provisions in E-liquid Promotion Posts on Instagram

Improving Enforcement Measures and Establishing Clear Criteria: A Content Analysis of Tobacco-Brand-Owned Instagram Accounts

INTRODUCTION

This study examines limitations of the current regulatory framework for tobacco advertising on Instagram. We first investigate compliance with Food and Drug Administration (FDA) warning label requirements for posts by tobacco-owned accounts. Next, we examine the prevalence of content that has been restricted in broadcast or print for its youth appeal, followed by content meeting more expansive criteria for youth appeal set forth in the FDA's guidance document.

AIMS AND METHODS

Posts by tobacco-brand-owned accounts between January 1, 2021, and February 14, 2022, were sampled from Mintel's Comperemedia Omni database. Instagram posts from 15 accounts were examined for violations of FDA warning label requirements and content that has been restricted on other mediums, including cartoons, sports branding, unauthorized claims, and young models (N = 1243). Finally, a subsample of n = 453 unambiguously branded posts was coded for themes that met the FDA's criteria of resonating with younger audiences, particularly that "adolescents rely on external information as they seek to shape their own identities."

RESULTS

Only 12.8% of posts had fully compliant warning labels. Content that has been in some way regulated on other mediums, such as cartoons (1.6%), unauthorized health claims (<1%), sports branding (<1%), and young models (4.4%) were infrequent. However, a conservative analysis focusing only on branded posts found that posts frequently highlighted tech elements (45%), device customizability (24.5%), vaper identity (17.7%), stylized product photography (33.6%), social media engagement (32.2%), and memes (5.7%).

CONCLUSIONS

Enforcement of existing regulations on Instagram is minimal. Explicit content restrictions applying evidence-based guidance on youth-appealing advertising are needed.

IMPLICATIONS

This research has important implications for enforcing and expanding advertising regulations on social media. First, Instagram's self-imposed regulations are ineffective, permitting tobacco companies to post ads from brand-owned accounts despite claiming to restrict tobacco promotion on the platform. Second, policymakers should seek to apply FDA guidance on youth-appealing advertising informed by decades of research to create explicit enforceable content restrictions that extend beyond cartoons, sports figures, and young models to include content likely to situate tobacco use within the developing self-concept of vulnerable youth such as presenting e-cigarettes as hi-tech devices, highlighting vaper identity, or infiltrating online social media culture. Finally, greater resources for enforcement are needed given the only applicable regulation, warning labels, remains largely ignored.

Characteristics of Adolescents' and Young Adults' Exposure to and Engagement with Nicotine and Tobacco Product Content on Social Media

To inform policy and messaging, this study examined characteristics of adolescents' and young adults' (AYAs') exposure to and engagement with nicotine and tobacco product (NTP) social media (SM) content. In this cross-sectional survey study, AYAs aged 13-26 (N=1,163) reported current NTP use, SM use frequency, and exposure to and engagement with SM content promoting and opposing NTP use (i.e. frequency, source[s], format[s], platform[s]). Participants who used NTPs (vs. did not use) were more likely to report having seen NTP content (p-values<.001). Prevalent sources were companies/brands (46.6%) and influencers (44.4%); prevalent formats were video (65.4%) and image (50.7%). Exposure to content promoting NTP use was prevalent on several popular platforms (e.g. TikTok, Instagram, Snapchat); exposure to content opposing NTP use was most prevalent on YouTube (75.8%). Among those reporting content engagement (i.e. liking, commenting on, or sharing NTP content; 34.6%), 57.2% engaged with influencer content. Participants reported engaging with content promoting and opposing NTP use on popular platforms (e.g. TikTok, Instagram, YouTube). Participants with (versus without) current NTP use were significantly more likely to use most SM platforms and to report NTP content exposure and engagement (p-values<.05). Results suggest that NTP education messaging and enforcement of platforms' content restrictions are needed.

US adolescents' response to nicotine warning labels in influencer e-cigarette marketing social media posts: a survey-based randomised between-subject experiment

BACKGROUND

E-cigarette promotional posts with misleading nicotine warning labels on social media may lower adolescents' risk perceptions of e-cigarettes. A between-subject experiment assessed effects of influencers' e-cigarette promotional posts with different nicotine warning labels on adolescents' e-cigarette harm perceptions, susceptibility to e-cigarette use and perceptions of influencer credibility.

METHODS

In 2022, adolescents (N=1864, Mage=17 (SD=0.6)) were randomised to view six images and videos featuring influencers promoting e-cigarettes in one of five experimental conditions: two conditions with a 'tobacco-free nicotine' warning label (placed on an e-cigarette in the post or at the top of the post), two conditions with the US Food and Drug Administration (FDA) nicotine warning label (on an e-cigarette in the post or at the top of the post (control)) and one no-label condition. Participants rated influencers' credibility (eg, honesty). Harm perceptions of, and susceptibility to use, e-cigarettes were then assessed.

RESULTS

Participants who viewed posts with the FDA warning label at the top of the post perceived influencers as more honest, trustworthy and informed than in all the other conditions. E-cigarette never-users who viewed posts with a 'tobacco-free nicotine' warning label pictured on an e-cigarette (compared with the FDA label at the top of a post) were more likely to report susceptibility to e-cigarette use (adjusted OR 1.79, 95% CI 1.17 to 2.73).

CONCLUSIONS

Alterations of the required nicotine warning labels can make them less effective in deterring e-cigarette use behaviour. Tobacco control authorities could increase enforcement of the FDA-required nicotine warning labels and harness influencers for antitobacco messaging.

Exploring the Influence of E-cigarette Ad Features on Perceived Product Appeal and Use Interest Among Young Adults of Varying Tobacco-Use Behaviors

INTRODUCTION

Exposure to certain features in commercial e-cigarette ads may influence e-cigarette use perceptions. This study explored the reactions toward common features in e-cigarette ads among young adults of various tobacco-use behaviors.

AIMS AND METHODS

We used data from in-depth interviews with U.S. young adults (ages 18-29) who do not use tobacco (n = 26) and who currently smoke cigarettes (n = 26). Participants viewed 30 print e-cigarette ads that included multiple features (eg, fruit flavors, price promotions, smoker-targeted messages) before discussing their perceived influence of memorable ad features. We used reflective thematic analysis to analyze interview data.

RESULTS

Participants from both groups generally noticed fruit and multiple flavors displayed in the ads, which were seen as appealing and were reported to generate product-use interest because of bright colors, sensory appeal, and a variety of flavor options. Participants who smoke perceived price promotions and positive experience testimonials to be appealing, and some reported this generated use interest. Participants from both groups perceived smoker-targeted messages to be unconvincing, and reported this dampened ad and product appeal and use interest. Participants who do not use tobacco perceived nicotine warnings to be unappealing, resulting in reduced perceived appeal of other attractive features (eg, fruit flavors) appearing in the same ads.

CONCLUSIONS

Marketing features appearing in e-cigarette ads may be perceived by young adults of various tobacco-use behaviors in both similar and different ways. Communication and policy strategies that account for these differential perceptions towards various marketing features are needed to reduce the negative impact of e-cigarette marketing.

IMPLICATIONS

This study revealed evidence related to young adults' reactions to and perceived influence of commonly used marketing features (eg, fruit flavors, nicotine warnings, price promotions, smoker-targeted messages) in commercial e-cigarette ads. The results highlight the similar and differential perceived appeal and use interest of e-cigarette products promoted with various marketing features among young adults of different tobacco-use behaviors. The results have implications for informing the design of communication strategies and policies related to e-cigarette marketing aimed at promoting complete product switching among young adults who smoke while simultaneously deterring e-cigarette use interest among those who do not use tobacco.

Tobacco, nicotine and counter-marketing promotions using Instagram's branded content tool

BACKGROUND

The social media conglomerate, Meta, has a policy prohibiting promotion of tobacco products, vaporisers, electronic cigarettes or other products that simulate smoking via their branded content tools. This study examines if branded Instagram posts comply with these self-regulatory efforts.

METHODS

We analysed the presence and content of tobacco/nicotine promotion, as well as counter-marketing, in a sample of 400 branded/paid partnership-labelled Instagram posts with tobacco/nicotine-related terms made between 31 July 2022 and 31 March 2023, gathered from Meta's CrowdTangle tool and classified by CrowdTangle as being in English.

RESULTS

Of the 217 active branded posts that mentioned or depicted tobacco/nicotine products, most promoted rather than countered the sale of such products (84.3% vs 15.7%, respectively). Posts originating from US Instagram users accounted for 42.6% of promotional content. After the USA, posts from Indonesia (19.1%), Pakistan (9.8%) and India (8.2%) were most frequent. Most posts were fully in English (74.9%). Posts featured hookah (39.4%), electronic nicotine delivery systems (ENDS) accessories (17.5%), ENDS devices and e-liquids (16.9%) and various types of cigars (15.3%). The majority of US posts promoted venues or events where tobacco/nicotine products were featured (71.8%). Almost half of all promotional posts (47.0%) were sponsored by tobacco industry accounts. Posts that encouraged cessation were primarily (47.1%) sponsored by non-government organisations.

CONCLUSION

Despite attempts at self-regulation, paid partnership posts promoting tobacco and nicotine products are present on Instagram, especially posts promoting venues and events that feature tobacco and nicotine use. Self-regulation of this content shows limited success, suggesting a need for federal oversight and additional counter-marketing in social media settings.

Noticing people, discounts and non-tobacco flavours in e-cigarette ads may increase e-cigarette product appeal among non-tobacco-using young adults

INTRODUCTION

Young adults new to tobacco (including e-cigarettes) are at an increased risk of e-cigarette use after e-cigarette exposure. This study examined the association between noticing e-cigarette advertising features and perceived product appeal among non-tobacco-using young adults.

METHODS

A sample of non-tobacco-using young adults (ages 18-29 years; n=1993) completed an online survey in 2021. We content analysed visible features from 12 e-cigarette ads that represented commonly used e-cigarette brands. Participants viewed the ads and clicked on the areas of the ads that drew their attention. Participants reported e-cigarette product appeal for each ad, including ad liking, product curiosity and use interest. We used generalised estimating equations to examine within-person associations between noticing specific ad features and reporting each and any type of product appeal, adjusting for noticing other features and participant characteristics.

RESULTS

Noticing people, discounts, non-tobacco (menthol and mint/fruit) flavours, positive experience claims or product images was positively associated with having any e-cigarette product appeal. Noticing discounts or mint/fruit flavours was also positively associated with e-cigarette use interest. In contrast, noticing nicotine warnings or smoking cessation claims was negatively associated with ad liking and product curiosity.

CONCLUSIONS

Attention to several e-cigarette ad features (eg, people, discounts, non-tobacco flavours) was associated with increased e-cigarette product appeal, whereas attention to nicotine warnings and smoking cessation claims was associated with reduced appeal among non-tobacco-using young adults. Restricting appeal-promoting features while strengthening the effects of nicotine warnings and smoker-targeted claims in e-cigarette ads may potentially reduce e-cigarettes' overall appeal among this priority population.

Why and how should children be protected from the deluge of vaping related media and marketing overexposure?

E-cigarettes are products delivering nicotine via inhalation and are devised to mimic tobacco smoking. While they were initially introduced as a device putatively to aid with smoking cessation, their use is now far broader than that. Use by children is significantly increasing. There is growing evidence of the potential harms of vaping. E-liquids used for e-cigarettes contain a wide range of harmful substances, and the clinical consequences of this are now being increasingly demonstrated, such as the rise in cases of e-cigarette- or vaping-associated lung injury. In addition, early use may result in long-term nicotine addiction. Vaping companies utilise marketing methods that distinctly target young people, and weak legislation in the UK allows them free rein to expose children to vaping. In this review we demonstrate why children must be protected from vaping. We must have stringent legislation to prevent easy access to e-cigarettes, including banning the convenience and affordability disposable vapes provide, and prevent marketing that does not warn about the potential health effects. The Australia approach of prescription or pharmacy only access for smoking cessation should be considered to limit exposure of children and minimise use by nonsmokers.

A systematic review for the impacts of global approaches to regulating electronic nicotine products

Background

The rapid increase in electronic nicotine product (ENP) use among young people has been a global public health challenge, given the potential harm of ENPs and nicotine dependence. Many countries have recently introduced legislations to regulate ENPs, but the impacts of these policies are poorly understood. This systematic review aims to critically synthesise empirical studies on the effects of global regulations regarding ENPs on the prevalence of use, health outcomes and their determinants, using the 4A marketing mix framework (acceptability, affordability, accessibility and awareness).

Methods

Following the PRISMA guideline, we searched PubMed, Embase, Scopus, Web of Science, Academic Search Complete, Business Source Complete, and APA PsycINFO databases from inception until June 14, 2022 and performed citation searches on the included studies. Reviewed literature was restricted to peer-reviewed, English-language articles. We included all pre-post and quasi-experimental studies that evaluated the impacts of e-cigarette policies on the prevalence of ENP use and other health outcomes. A modified Joanna Briggs Institute (JBI) Critical Appraisal checklist for quasi-experimental studies was used for quality assessment. Due to heterogeneity of the included studies, we conducted a narrative synthesis of evidence.

Results

Of 3991 unduplicated records screened, 48 (1.2%) met the inclusion criteria, most were from high-income countries in North America and Europe and 26 studies measured self-reported ENPs use. Flavour restrictions significantly decreased youth ENP use and taxation reduced adult use; mixed results were found for the impacts of age restrictions. Indoor vaping restrictions and the European Tobacco Products Directive (TPD) did not seem to reduce ENP use based on existing studies. Changes in determinants such as sales and perceptions corroborated our conclusions. Few studies assessed the impacts of other regulations such as advertising restrictions and retail licensing requirements.

Conclusions

Flavour restrictions and taxes have the strongest evidence to support effective control of ENPs, while others need powerful enforcement and meaningful penalties to ensure their effectiveness. Future research should focus on under-examined policies and differential impacts across sociodemographic characteristics and countries.

Registration

PROSPERO CRD42022337361.

E-cigarette brands and social media influencers on Instagram: a social network analysis

BACKGROUND

Exposure to visual posts featuring e-cigarette products on social media is associated with increased e-cigarette use among US adolescents. Instagram is the largest source of e-cigarette social media marketing, where influencers-for example, bloggers, brand ambassadors-post promotional materials. This study analysed the network of e-cigarette brands and influencers on Instagram, characterising the most central players in e-cigarette social media marketing.

METHODS

We tracked influencers with public profiles on Instagram who posted promotional e-cigarette content in 2020, had over 1000 followers and high user engagement rate (ratio of likes and comments to followers) of 1%-25% per post. By conducting a social network analysis, we identified the most central (highly involved in promotional activities) influencers and e-cigarette brands. The number of the influencers' followers aged 13-17 years old and the age verification practices restricting youth access were also assessed.

RESULTS

There is a highly interconnected network of engaging e-cigarette influencers (n=55) worldwide who collaborated with over 600 e-cigarette brands in 2020. The Asian and US influencers had five to six times more teenage followers compared with the European influencers. 75% of the influencers did not restrict youth access to their promotional content on Instagram. The brands Voopotech, Innokin, Geekvape, Lost Vape, Smok and Vaporesso collaborated with the largest number of influencers (mean n=20).

CONCLUSIONS

It is important to understand associations among influencers and e-cigarette use behaviours, especially youth, to inform effective public health communication and potential policies that could regulate social media marketing sponsored by e-cigarette companies.

U.S. digital tobacco marketing and youth: A narrative review

We describe findings from peer-reviewed articles on digital tobacco marketing (DTM) using U.S. data related to youth, including research that examines use of age restrictions, DTM exposure and engagement, and associated tobacco use. We searched PubMed, EMBASE, Web of Science, and EBSCOhost in May 2019 and May 2020 for published English language peer-reviewed articles examining DTM that were published from January 2016 to May 2020. Inclusion coding occurred in three stages. The first search identified 519 articles; 167 were coded for inclusion. The second search identified 189 articles; 67 were coded for inclusion. Two coders then assessed whether the included articles mentioned youth (age 18 and younger) or age restrictions in the method and results sections of the full text. Ultimately, 47 articles were included in this review. A codebook was developed and tested through training. Each article was coded for age restrictions, youth exposure to DTM, youth engagement with DTM, and youth tobacco use associated with DTM exposure or engagement. The studies reviewed indicate that DTM on social media was infrequently age-restricted and the stringency of age restriction varied by tobacco product, site owner, and channel. Youth reported being exposed to DTM frequently via the Internet. While youth reported less frequently engaging with DTM compared to being exposed, engagement increased over time. DTM exposure and engagement were associated with tobacco product use. The studies reviewed document an association between DTM exposure and engagement and future tobacco use; thus, DTM may be contributing to the youth tobacco epidemic.

Examining influencer compliance with advertising regulations in branded vaping content on Instagram

Background

Youth and young adults are exposed to vaping advertisements on social media sites, despite regulations and guidelines intended to reduce the prevalence of such content on these platforms. This research uses replicable criteria to identify vaping influencers who have worked with vaping brands to promote vaping products on Instagram and documents the extent to which posts by these users comply with existing advertising regulations.

Methodology

We conducted three google searches collecting eight different vaping influencer lists, with a total of 575 unique influencers. We limited our sample to public accounts with 100,000 followers or more (n = 54). An initial sample of 360 Instagram posts was used to identify an analytic sample of 262 vape-related posts from 2021. We conducted a conceptual content analysis to first identify unambiguous vaping advertisements (branded content), and then code ads for compliance with existing regulations.

Results

On average, the 54 Instagram accounts had 265,851.9 followers (sd = 383,349.8) and 4,158 posts (sd = 7,302.1). Most posts featured vaping products 239 (91.2%), with 186 (76.2%) posts being unambiguously branded vape advertisements and 31 (14.3%) even including purchase links in the post itself. However, one post complied with FTC disclosure guidelines. Although 50 (20.9%) had warning labels, only 8 (15.1%) were fully compliant with FDA warning label guidelines.

Discussion

Findings demonstrate minimal compliance with existing regulations among influencers known to have financial relationships with vaping brands. Most influencer posts are unambiguous, branded, vaping advertisements. Implications for barriers to regulating influencer content and the need for greater enforcement resources are discussed.

Longitudinal associations between U.S. youth exposure to E-cigarette marketing and E-cigarette use harm perception and behavior change

E-cigarette marketing tactics to reach and appeal to youth are rapidly changing. This study examined to what extent youth e-cigarette marketing exposure was associated with e-cigarette use behavior change one year later, during a time when youth e-cigarette use was starting to surge in the U.S. Using nationally representative longitudinal public-use data from the Population Assessment of Tobacco and Health (PATH) Study, we examined associations between recalled e-cigarette marketing exposure (2016-2018) at Wave (W) 4 and e-cigarette use harm perception and behavior change (ever, current, and regular use) one year later (W4.5; 2017-2018) among W4 never tobacco users (n = 9405). Recall of exposure to e-cigarette marketing through different channels was also examined in multivariable models controlling for socio-demographic factors and established e-cigarette use risk factors. Results show that the most frequently recalled channels of e-cigarette marketing exposure were retail stores (50.3%), television (22.2%), and websites/social media (20.2%). Over one year, 21.2%, 7.8%, 3.4%, and 1.2% of respondents reported reduced harm perceptions, and ever, current, and regular use of e-cigarettes, respectively, at follow-up. Recalled exposure to e-cigarette marketing was associated with reduced e-cigarette harm perception (AOR = 1.20; 95% CI = 1.05-1.37) and ever (AOR = 1.26; 95% CI = 1.01-1.56) and current use (AOR = 1.40; 95% CI = 1.02-1.92) at follow-up. E-cigarette marketing exposure through websites/social media was associated with reduced harm perceptions and all stages of e-cigarette use change, including regular use. Identifying marketing techniques and channels that change youth e-cigarette harm perceptions and influence e-cigarette use progression is essential to inform e-cigarette regulatory policies and prevention campaigns.

Presence of Nicotine Warning Statement on US Electronic Nicotine Delivery Systems (ENDS) Advertisements 6 Months Before and After the August 10, 2018 Effective Date

INTRODUCTION

Effective in August 10, 2018, FDA requires advertisements for electronic nicotine delivery systems (ENDS) that meet the definition of a "covered tobacco product" to feature a standard nicotine warning statement. To date, limited data exist on the presence of warning statements in ENDS advertising.

METHODS

We acquired ENDS ads (n = 459) that first ran six months before (February 10, 2018-August 9, 2018) and after (August 10, 2018-February 9, 2019) the effective date. The sample included online, print, and outdoor static ads (ie, without video or animated graphics) (n = 166 before, n = 198 after), online and television video ads (n = 16 before, n = 49 after), and radio ads (n = 9 before, n = 21 after). We coded ads for the presence of the verbatim FDA warning. Ads with verbatim warnings were coded for required formatting and additional features.

RESULTS

Overall, 28% of static (n = 46/166), 62% of video (n = 10/16), and 67% of radio (n = 6/9) ads that ran before the effective date contained the verbatim warning versus 84% (n = 167/198, p < .001), 96% (n = 47/49, p = .002), and 86% (n = 18/21, p =.329) of ads that ran after, respectively. Following the effective date, nearly all static ads placed the warning as required at the top of the ad (76% [n = 35/46] before, 97% [n = 162/167] after, p < .001), and many video ads featured the warning statement for the entire ad duration (0% [n = 0/10] before, 60% [n = 28/47] after, p < .001). Half (n = 9/18) of radio warnings running after the effective date were read faster than the other promotional content.

CONCLUSIONS

The presence of the nicotine warning statement on paid promotional static, video, and radio ENDS ads in this sample increased after August 10, 2018, but a notable number still lacked the warning.

IMPLICATIONS

Results from this study provide initial insights into the extent to which required nicotine warning statements appear in ENDS ads in the study sample across traditional (eg, magazines, television, radio) and digital (eg, online/mobile ads) advertising mediums. Following the August 10, 2018, effective date, we observed a substantial increase in the presence of the required FDA warning statement on the ENDS ads in this sample. However, a notable number of ads in the study lacked the required warning and warnings did not always include the required formatting displays.

Health Claims, Marketing Appeals, and Warnings on Popular Brands of Waterpipe Tobacco Packaging Sold in the United States

INTRODUCTION

Waterpipe tobacco (WT) smoking is associated with misperceptions of harm, especially among users. WT packaging contains imagery, flavor descriptors, and text claims that may contribute to misperceptions. The study goal was to characterize visual and text elements of WT packaging.

AIMS AND METHODS

Using data from the U.S. Population Assessment on Tobacco and Health Study Wave 2 (October 2014-October 2015), we identified the 10 most popular WT brands. For each brand, we identified available flavors, including flavor collections with unique packaging elements. We randomly selected 10 flavors per brand for purchase (March-April 2018). We conducted descriptive content analysis to code all textual and visual design elements of each package.

RESULTS

Over half (54%) of WT packages had modified risk tobacco product (MRTP) claims prohibited by federal law, including substance-free MRTP claims (43%) and the descriptor "natural" (11%). No MRTP reduced exposure or reduced risk claims were found. Over a quarter (26%) of packaging including one or more of terms that may imply reduced harm including "fresh," "premium," "quality," and "pure." All packages included a text-only warning, yet none appeared on the primary display panel. Almost all packaging (99%) included imagery, with 72% including flavor imagery. The majority of packages (72%) included a smoking cue. The most popular marketing appeals were "well-made" (57%), "enjoyable" (55%), and "patriotic" (47%).

CONCLUSIONS

Prohibited MRTP claims, other descriptors, and flavor imagery are common on WT packaging, despite federal law. Future research is needed to evaluate if this marketing contributes to misperceptions of reduced harm.

IMPLICATIONS

Tobacco packaging is used to convey health-related messages, both explicitly and implicitly; however, information about WT packaging is virtually nonexistent. We conducted a content analysis of WT packaging from the 10 most popular US brands. Over half (54%) of packages had prohibited MRTP claims and over a quarter (26%) included one or more descriptors that may be perceived as implying reduced harm. Use of imagery, including smoking cues, was common. The widespread use of prohibited MRTP claims, other descriptors, and imagery on WT packaging may contribute to misperceptions of reduced harm.