#FlavorsSaveLives: An Analysis of Twitter Posts Opposing Flavored E-cigarette Bans

Exploring #MentholBan on TikTok: A Thematic and Semantic Network Analysis

INTRODUCTION

In April 2021, the U.S. Food and Drug Administration (FDA) announced its intention to ban the sale of menthol cigarettes and cigars. Decades of research support the premise that a menthol ban will reduce initiation and disparities in tobacco-related disease among menthol smokers. The tobacco industry opposed such a policy and worked for decades to shape public opposition. Social media discourse can inform our understanding of public opinion about the proposed ban and guide communication strategies and policy implementation.

AIMS AND METHODS

This research employed a mixed-methods design to explore TikTok posts discussing the announced menthol ban. Using a TikTok web scraper to extract all content in the #mentholban hashtag (n = 171), we coded for 11 themes, characterized content with descriptive statistics, and created a semantic network of co-occurring hashtags.

RESULTS

We found primarily negative attitudes towards the U.S. ban announcement and a large volume of menthol "hacks" to circumvent the bans. Our semantic network analysis revealed strong co-occurrences between #mentholban and popularity-seeking hashtags. The metadata associated with each TikTok demonstrated that most posters in #mentholban are not "influencers" in the sense of having many followers, aside from a few niche organizations with multiple posts. We found that perceived political and racial motivations shaped posters' assessments of the menthol ban. Furthermore, we uncovered how individuals and organizational actors shaped menthol ban content on TikTok.

CONCLUSIONS

Our study indicates targeted marketing from alternative menthol product companies and advocacy organizations. The latter of these organizations is more likely to saturate the TikTok landscape with multiple posts and strategic hashtags.

IMPLICATIONS

This study pursued an exploration of tobacco policy discussion on TikTok, specifically related to the FDA-proposed menthol ban. TikTok is a newer platform and our study provides early evidence of policy discussion emerging there, including the types of accounts creating the content and their valence toward the policy.

#Discreetshipping: Selling E-cigarettes on TikTok

INTRODUCTION

Youth and young adult use of e-cigarette products continues to remain high despite regulatory approaches to reduce youth access. This study sought to examine TikTok content regarding the sale and distribution of e-cigarettes.

AIMS AND METHODS

TikTok videos (n = 475) and metadata posted between June 2022 and August 2023 were scraped using a TikTok application programming interface and popular hashtags used to sell vaping products (ie, #discreetshipping [40.8 million], #puffbundle [14.8 million], #hiddennic [1.0 million]). After watching the 25 most viewed videos (39 600-868 800 views), a codebook was developed. All metadata were annotated using 11 unique codes: Small business, brand, cannabis, bundled, hidden, fake, international sales, no ID, order via Instagram, order via another method, and cost.

RESULTS

Overall, 367 videos (with an average of 2017 likes) were deemed relevant. Videos advertised popular vaping brands (50.4%) that included cannabis products (45%). Products were described as bundled (28.6%), hidden (8.7%), and able to be shipped internationally (6%) without age verification (45.2%). Some videos (8.2%) evaded algorithms' detection of illegal activity by describing the post as "Fake." Customers were directed to other social media platforms (most often Instagram, 57.5%) and/or other websites/links (58.3%) to purchase products; 22.1% advertised discounts, free shipping, or low costs (ranging from $25-$35).

CONCLUSIONS

Social media platforms, such as TikTok and Instagram, are being used to circumvent e-cigarette regulatory policies. Regulatory agencies should expand enforcement strategies to include social media platforms where users are illegally selling and distributing e-cigarettes internationally to young audiences.

IMPLICATIONS

TikTok users across the globe are violating local, state, and federal laws by selling e-cigarettes concealed inside other products or bundled in packages that avoid detection. TikTok videos posted by self-proclaimed small business owners advertise discreet shipping practices that evade age verification in order to sell nicotine and cannabis bundles worldwide. Accounts used phrases describing the post to be "fake" to avoid detection by algorithms or TikTok administrators. E-cigarette regulatory agencies can partner with social media platforms to close regulatory gaps.

Assessing the public discourse on Twitter: Reactions to the JUUL e-cigarettes ban in the United States

INTRODUCTION

JUUL is a high-nicotine pod-based vaping device that is popular among adolescents and young adults. On 23 June 2022, the US Food and Drug Administration (FDA) denied authorization to market JUUL, and ordered JUUL Labs to remove products from the US market. The next day, a US federal appeals court temporarily suspended the ban. The mixed public discourse surrounding the FDA ban warrants further investigation.

METHODS

This study examined Twitter data to describe public reaction to these announcements. Posts containing terms 'JUUL' and/or '#JUUL' (N=97548 unique tweets) were collected from 23 June to 3 July 2022, from Twitter's Streaming Application Programming Interface (API). After removing retweets, we used an inductive approach to become familiar with the data, generated a codebook, and conducted a content analysis on a random sample of n=4000 tweets.

RESULTS

A total of 2755 (68.9%) tweets discussed JUUL in the context of the FDA ban. News (n=1425/2755; 51.7%) about the JUUL ban, government distrust (n=588; 21.3%), and individual rights (n=253; 9.2%) were the most prevalent themes. Less commonly discussed themes included inconsistencies between policies (n=174; 6.3%), mentions of switching to other products (n=162; 5.9%), smoking cessation (n=99; 3.6%), and craving for JUUL (n=94; 3.4%). Sentiment analysis of JUUL ban-related posts (n=2755) demonstrated that 1989 (72.2%) tweets were categorized as neutral, while anti-ban posts (n=566; 20.5%) were more prevalent than pro-ban posts (n=200; 7.3%).

CONCLUSIONS

Besides straightforward announcements of the JUUL ban and its suspension, Twitter posts discussed government distrust, individual rights, and policy inconsistencies. While most posts conveyed neutral sentiments, anti-ban posts were almost three times more prevalent than pro-ban posts. Our findings suggest that text-based social media platforms like Twitter may be an effective instrument to understand opinions, attitudes, and beliefs regarding the FDA's JUUL ban.

Twitter Sentiment About the US Federal Tobacco 21 Law: Mixed Methods Analysis

BACKGROUND

On December 20, 2019, the US "Tobacco 21" law raised the minimum legal sales age of tobacco products to 21 years. Initial research suggests that misinformation about Tobacco 21 circulated via news sources on Twitter and that sentiment about the law was associated with particular types of tobacco products and included discussions about other age-related behaviors. However, underlying themes about this sentiment as well as temporal trends leading up to enactment of the law have not been explored.

OBJECTIVE

This study sought to examine (1) sentiment (pro-, anti-, and neutral policy) about Tobacco 21 on Twitter and (2) volume patterns (number of tweets) of Twitter discussions leading up to the enactment of the federal law.

METHODS

We collected tweets related to Tobacco 21 posted between September 4, 2019, and December 31, 2019. A 2% subsample of tweets (4628/231,447) was annotated by 2 experienced, trained coders for policy-related information and sentiment. To do this, a codebook was developed using an inductive procedure that outlined the operational definitions and examples for the human coders to annotate sentiment (pro-, anti-, and neutral policy). Following the annotation of the data, the researchers used a thematic analysis to determine emergent themes per sentiment category. The data were then annotated again to capture frequencies of emergent themes. Concurrently, we examined trends in the volume of Tobacco 21-related tweets (weekly rhythms and total number of tweets over the time data were collected) and analyzed the qualitative discussions occurring at those peak times.

RESULTS

The most prevalent category of tweets related to Tobacco 21 was neutral policy (514/1113, 46.2%), followed by antipolicy (432/1113, 38.8%); 167 of 1113 (15%) were propolicy or supportive of the law. Key themes identified among neutral tweets were news reports and discussion of political figures, parties, or government involvement in general. Most discussions were generated from news sources and surfaced in the final days before enactment. Tweets opposing Tobacco 21 mentioned that the law was unfair to young audiences who were addicted to nicotine and were skeptical of the law's efficacy and importance. Methods used to evade the law were found to be represented in both neutral and antipolicy tweets. Propolicy tweets focused on the protection of youth and described the law as a sensible regulatory approach rather than a complete ban of all products or flavored products. Four spikes in daily volume were noted, 2 of which corresponded with political speeches and 2 with the preparation and passage of the legislation.

CONCLUSIONS

Understanding themes of public sentiment-as well as when Twitter activity is most active-will help public health professionals to optimize health promotion activities to increase community readiness and respond to enforcement needs including education for retailers and the general public.

To Tweet or Not to Tweet: Tweets About Tobacco Regulation can Help Disseminate Anti-regulatory Messages

INTRODUCTION

Twitter enables public organizations to engage the public in health policy discourse. However, documented hostility towards tobacco control proposals on Twitter suggests that a closer examination of the nature of interaction with such content is warranted.

AIMS AND METHODS

We scraped tweets from government bodies with tobacco control interests between July and November of 2021 (N = 3889), 2 months before and after the Food and Drug Administration's (FDA) Premarket Tobacco Authorization Act's (PMTA) September deadline. PMTA is a review process for authorizing the sale of new and existing e-cigarette or vaping products. Tweets related to PMTA were identified (n = 52) using a keyword filter. A content analysis of quote tweets and replies examined the amplification of pro and anti-policy sentiment via likes and retweets.

RESULTS

Replies were overwhelmingly anti-policy (96.7%). Moreover, the amplification of these replies, including 83.3% of likes and 65.6% of retweets, amplified anti-policy replies. Quote tweets, which allow users to add their own commentary to an existing tweet, were 77.9% (n = 120) anti-policy, receiving 87.7% of likes (n = 1708) and 86.2% of retweets (n = 726) compared to pro-policy quote tweets (n = 240 likes and n = 116 retweets). Regression analyses showed a significantly greater amplification of anti-policy content.

CONCLUSIONS

Communicating about tobacco policy on Twitter carries risks. Anti-policy advocates can weaponize quote tweets for easy construction of messages designed in accordance with evidence-based guidelines for conferring resistance to persuasion. Future research should examine whether public health organizations can adapt this strategy to counter anti-regulatory advocates on Twitter.

IMPLICATIONS

The primary implications of this research are that communication about tobacco policy on Twitter should be part of a broader public engagement strategy with quantifiable metrics of success. The information environment on Twitter is demonstrably hostile to pro-tobacco regulatory policy positions. As a result, efforts to engage on the platform by regulatory institutions like the FDA can inadvertently provide materials that are easily leveraged as effective counter-messaging. Moreover, this counter-messaging can disseminate more broadly than the original message.

An Analysis of Twitter Posts About the U.S. Food and Drug Administration's Menthol Ban

INTRODUCTION

Although the U.S. Food and Drug Administration (FDA) banned characterizing flavors in cigarettes in 2009, this initial ban exempted menthol. After examining numerous reports on the adverse health effects of menthol cigarettes, the FDA proposed a menthol ban in April 2022. This study analyzed Twitter data to describe public reaction to this announcement.

AIMS AND METHODS

Posts containing the word "menthol" and/or "#menthol" were collected from April 21, 2022 to May 5, 2022 from Twitter's Streaming Application Programming Interface (API). A random sampling procedure supplied 1041 tweets for analysis. Following an inductive approach to content analysis, posts were classified into one or more of 11 themes.

RESULTS

Posts discussed the FDA announcement (n = 153, 14.7%), racial discrimination (n = 101, 9.7%), distrust in government (n = 67, 6.4%), inconsistencies between policies (n = 52, 5.0%), public health benefits (n = 42, 4%), freedom of choice (n = 22, 2.1%), and health equity (n = 21, 2.0%). Posts contained misinformation (n = 20, 1.9%), and discussed the potential for illicit markets (n = 18, 1.7%) and the need for cessation support (n = 4, 0.4%). 541 (52.0%) tweets did not fit into any of the prescribed themes.

CONCLUSIONS

Twitter posts with the word "menthol" commonly discussed distrust in government and mentioned racial discrimination. Findings demonstrated the possibility of near real-time Twitter monitoring of public opinion on a menthol ban. These data may be valuable for designing tobacco control health communication campaigns in the future.

IMPLICATIONS

The U.S. FDA proposed a ban on menthol cigarettes in April 2022. This study's content analyzed Twitter posts over a 2-week period to understand the public's response to the proposed menthol ban. Twitter posts with the word "menthol" often discussed distrust in government and mentioned racial discrimination. Findings demonstrated the possibility of near real-time Twitter monitoring of public opinion of regulatory action. Findings underscore the need to educate the public about the potential health benefits of banning menthol from cigarettes, particularly for populations that experience tobacco-related health disparities.

The Experiences of Stakeholders Using Social Media as a Tool for Health Service Design and Quality Improvement: A Scoping Review

BACKGROUND

Health organisations and stakeholders use social media for a range of functions, including engaging stakeholders in the design and quality improvement (QI) of services. Social media may help overcome some of the limitations of traditional stakeholder engagement methods. This scoping review explores the benefits, risks, barriers and enablers for using social media as a tool for stakeholder engagement in health service design and QI.

METHODS

The searches were conducted on 16 August 2022. Inclusion criteria were: studies of any health service stakeholders, in any health setting, where social media was used as a tool for service design or QI. Data was analysed using deductive content analysis. A committee of stakeholders provided input on research questions, data analysis and key findings.

RESULTS

61 studies were included. Benefits included improved organisational communication and relationship building. Risks/limitations included low quality of engagement and harms to users. Limited access and familiarity with social media were frequently reported barriers. Making discussions safe and facilitating access were common enablers.

CONCLUSION

The benefits, risks, barriers and enablers identified highlight the complexity of social media as an engagement tool for health service design and QI. Understanding these experiences may help implementers design more effective social media-based engagement activities.

Attitudes towards the 'Shisha No Thanks' campaign video: Content analysis of Facebook comments

INTRODUCTION

While social media are commonly used in public health campaigns, there is a gap in our understanding of what happens after the campaign is seen by the target audience. This study aims to understand how the Shisha No Thanks campaign video was received by the Facebook audience by analyzing Facebook comments posted to it. Specifically, this study aims to determine whether the Facebook audience accepted or rejected the campaign’s message.

METHODS

A sample of the Facebook comments was extracted, and the study team, which included cultural support workers, developed content categories consistent with the research question. Each comment was then coded by three team members, and only assigned a category if there was agreement by at least two members.

RESULTS

Of the 4990 comments that were sampled, 9.1% (456) accepted the campaign message, 22.9% (1144) rejected the message, 21.8% (1089) were unclear, and 46.1% (2301) contained only tagged names. Of the sample, 2.8% (138) indicated the commenter took on board the campaign message by expressing an intention to stop smoking shisha, or asking a friend to stop smoking shisha. Of the comments that showed rejection of the campaign, the majority were people dismissing the campaign by laughing at it or expressing pro-shisha sentiments.

CONCLUSIONS

This study demonstrates that conducting content analyses of social media comments can provide important insight into how a campaign message is received by a social media audience.

Responses to potential nicotine vaping product flavor restrictions among regular vapers using non-tobacco flavors: Findings from the 2020 ITC Smoking and Vaping Survey in Canada, England and the United States

INTRODUCTION

Some jurisdictions have implemented nicotine vaping product (NVP) flavor restrictions because of concerns about rising adolescent use. However, little is known how these restrictions may impact adult vapers. This study describes the level of support and predictive behavioral responses to a hypothetical NVP ban on non-tobacco flavors among regular adult vapers who only use flavors that would be banned.

METHODS

Data came from 851 regular vapers (all current or ex-smokers) participating in the 2020 ITC Four Country Smoking and Vaping Survey in Canada, England, and the United States (US). A random sample of respondents in each country received and completed the questions about flavor bans: (1) do you support or oppose a ban on all non-tobacco flavors; and (2) what would you do if all flavors were banned, with the exception of tobacco in the US, and tobacco and menthol in Canada and England. Those who used tobacco-flavored or unflavored NVPs were excluded from all analyses, and additionally, vapers of menthol flavor in Canada and England were excluded from Aim 2.

RESULTS

Overall, 53.6% of vapers were strongly opposed to flavor bans, 28.2% were opposed, 9.3% were in support, 3.6% were in strong support, and 5.2% did not know. Predicted behavioral responses were: 28.8% would continue vaping an available flavor, 28.3% would find a way to get their banned flavor(s), 17.1% would stop vaping and smoke instead, 12.9% said that they would stop vaping and not smoke, and 12.9% do not know what they would do. Responses to a potential flavor ban largely varied by smoking and vaping status, and by the level of support of a flavor restriction policy.

CONCLUSIONS

At this time, it is not clear what net population-level consequences would occur if non-tobacco flavored NVPs were prohibited. While a majority of vapers in this study opposed this policy, and many vapers would not be willing to switch to available flavors, there was considerable variability in predicted behavioral responses.

Cannabis Vaping Among Youth and Young Adults: a Scoping Review

Purpose of Review

The purpose of this review was to describe the state-of-the-literature on research specific to cannabis vaping among youth and young adults.

Recent Findings

Out of 1801 records identified, a total of 202 articles met eligibility criteria for inclusion in this review. Most of this literature (46.0% of studies) was specific to the health effects of cannabis vaping, particularly EVALI (e-cigarette and vaping associated lung injury). Other research areas identified in the review included the etiology (24.3%) and epidemiology (24.8%) of cannabis vaping, in addition to articles on regulation (8.4%) and marketing (5.5%) of the same.

Summary

Cannabis vaping is increasingly common among youth and young adults and more prevalent is settings where recreational use for adults has been legalized. The literature documents a number of negative health effects of cannabis vaping for young people, along with risk factors and reasons for the same.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40429-022-00413-y.

Smokers' Likelihood to Engage With Information and Misinformation on Twitter About the Relative Harms of e-Cigarette Use: Results From a Randomized Controlled Trial

Background

Information and misinformation on the internet about e-cigarette harms may increase smokers’ misperceptions of e-cigarettes. There is limited research on smokers’ engagement with information and misinformation about e-cigarettes on social media.

Objective

This study assessed smokers’ likelihood to engage with—defined as replying, retweeting, liking, and sharing—tweets that contain information and misinformation and uncertainty about the harms of e-cigarettes.

Methods

We conducted a web-based randomized controlled trial among 2400 UK and US adult smokers who did not vape in the past 30 days. Participants were randomly assigned to view four tweets in one of four conditions: (1) e-cigarettes are as harmful or more harmful than smoking, (2) e-cigarettes are completely harmless, (3) uncertainty about e-cigarette harms, or (4) control (physical activity). The outcome measure was participants’ likelihood of engaging with tweets, which comprised the sum of whether they would reply, retweet, like, and share each tweet. We fitted Poisson regression models to predict the likelihood of engagement with tweets among 974 Twitter users and 1287 non-Twitter social media users, adjusting for covariates and stratified by UK and US participants.

Results

Among Twitter users, participants were more likely to engage with tweets in condition 1 (e-cigarettes are as harmful or more harmful than smoking) than in condition 2 (e-cigarettes are completely harmless). Among other social media users, participants were more likely to likely to engage with tweets in condition 1 than in conditions 2 and 3 (e-cigarettes are completely harmless and uncertainty about e-cigarette harms).

Conclusions

Tweets stating information and misinformation that e-cigarettes were as harmful or more harmful than smoking regular cigarettes may receive higher engagement than tweets indicating e-cigarettes were completely harmless.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 16082420; https://doi.org/10.1186/ISRCTN16082420

Characteristics of and User Engagement With Antivaping Posts on Instagram: Observational Study

BACKGROUND

Although government agencies acknowledge that messages about the adverse health effects of e-cigarette use should be promoted on social media, effectively delivering those health messages is challenging. Instagram is one of the most popular social media platforms among US youth and young adults, and it has been used to educate the public about the potential harm of vaping through antivaping posts.

OBJECTIVE

We aim to analyze the characteristics of and user engagement with antivaping posts on Instagram to inform future message development and information delivery.

METHODS

A total of 11,322 Instagram posts were collected from November 18, 2019, to January 2, 2020, by using antivaping hashtags including #novape, #novaping, #stopvaping, #dontvape, #antivaping, #quitvaping, #antivape, #stopjuuling, #dontvapeonthepizza, and #escapethevape. Among those posts, 1025 posts were randomly selected and 500 antivaping posts were further identified by hand coding. The image type, image content, and account type of antivaping posts were hand coded, the text information in the caption was explored by topic modeling, and the user engagement of each category was compared.

RESULTS

Analyses found that antivaping images of the educational/warning type were the most common (253/500; 50.6%). The average likes of the educational/warning type (15 likes/post) were significantly lower than the catchphrase image type (these emphasized a slogan such as "athletesdontvape" in the image; 32.5 likes/post; P<.001). The majority of the antivaping posts contained the image content element text (n=332, 66.4%), followed by the image content element people/person (n=110, 22%). The images containing people/person elements (32.8 likes/post) had more likes than the images containing other elements (13.8-21.1 likes/post). The captions of the antivaping Instagram posts covered topics including "lung health," "teen vaping," "stop vaping," and "vaping death cases." Among the 500 antivaping Instagram posts, while most posts were from the antivaping community (n=177, 35.4%) and personal account types (n=182, 36.4%), the antivaping community account type had the highest average number of posts (1.69 posts/account). However, there was no difference in the number of likes among different account types.

CONCLUSIONS

Multiple features of antivaping Instagram posts may be related to user engagement and perception. This study identified the critical elements associated with high user engagement, which could be used to design antivaping posts to deliver health-related information more efficiently.

Digital Surveillance to Identify California Alternative and Emerging Tobacco Industry Policy Influence and Mobilization on Facebook

Growing popularity of electronic nicotine-delivery systems (ENDS) has coincided with a need to strengthen tobacco-control policy. In response, the ENDS industry has taken actions to mobilize against public health measures, including coordination on social media platforms. To explore this phenomenon, data mining was used to collect public posts on two Facebook public group pages: the California Consumer Advocates for Smoke Free Alternatives Association (CCASAA) and the community page of the Northern California Chapter of SFATA (NC-SFATA). Posts were manually annotated to characterize themes associated with industry political interference and user interaction. We collected 288 posts from the NC-SFATA and 411 posts from CCASAA. A total of 522 (74.7%) posts were categorized as a form of political interference, with 339 posts (64.9%) from CCASAA and 183 posts (35.1%) from NC-SFATA. We identified three different categories of policy interference-related posts: (1) providing updates on ENDS-related policy at the federal, state, and local levels; (2) sharing opinions about ENDS-related policies; (3) posts related to scientific information related to vaping; and (4) calls to action to mobilize against tobacco/ENDS policies. Our findings indicate that pro-tobacco social media communities on Facebook, driven by strategic activities of trade associations and their members, may act as focal points for anti-policy information dissemination, grass-roots mobilization, and industry coordination that needs further research.