Are Cigarette Smokers', E-Cigarette Users', and Dual Users' Health-Risk Beliefs and Responses to Advertising Influenced by Addiction Warnings and Product Type?

Managing a policy paradox? Responses to textual warning labels on E-cigarette advertisements among U.S. national samples of youth overall and adults who smoke or vape

CONTEXT

Current use and potential future uptake of e-cigarettes among youth remain public health concerns in the U.S., even as people who smoke combustible cigarettes could benefit from switching completely to e-cigarettes. The U.S. Food and Drug Administration (FDA) is considering alternative warning messages, but warnings that discourage youth from use may also deter people who smoke from switching. This study tests ten pre-registered hypotheses on effects of warning messages with national samples of youth overall and adults who smoke and/or vape.

METHODS

NORC recruited 1639 adults (ages 18+) who smoke, vape, or use both products, from their probability-sampled AmeriSpeak Panel and augmented their AmeriSpeak Teen Panel with Lucid's nonprobability opt-in panel to recruit 1217 youth (ages 14-17) to participate in a web-based survey experiment. We randomly assigned respondents to view one of five warning label conditions and respond to measures of their e-cigarette risk beliefs, willingness to use e-cigarettes, and (among people who smoke or vape) considerations to quit these products.

FINDINGS

Relative to the current FDA warning about nicotine, warning messages about the harms of e-cigarette use for youth brain development did not influence risk beliefs or reduce willingness to use these products among youth. Brain development warning messages did increase beliefs about these harms among adults but did not increase quit considerations among people who vape, relative to the FDA warning. Warning messages with information about chemical constituents of vaping products and the harm of these chemicals produced higher e-cigarette quit considerations than did the FDA warning among adults who vape.

CONCLUSION

Potential alternative warning label messages were largely ineffective relative to the current FDA warning about nicotine, though limited evidence suggests some potential for chemical + harm messaging to encourage people who use both e-cigarettes and cigarettes to consider quitting both.

Examining Perceptions of Uncertain Language in Potential E-Cigarette Warning Labels: Results from 16 Focus Groups with Adult Tobacco Users and Youth

E-cigarette use among youth presents a public health risk. Yet, cigarette smokers who substantially reduce their smoking or switch completely from traditional combustible cigarettes could benefit. As science about e-cigarettes is continually emerging, any potential warnings are likely to contain uncertain language. Hedged verbiage may impact decision making. To assess reactions, we conducted 16 online focus groups; 8 with youth (n = 32, grouped by gender and by vaping experience) and 8 with adult tobacco users (n = 37, grouped by smokers, dual users of e-cigarettes and cigarettes, and former smokers who switched to e-cigarettes). Each focus group viewed and discussed 8 potential warnings messages. We conducted an inductive thematic analysis of the reactions to warning messages that contain uncertain language. Respondents' reactions were often negative, but varied based on specific usages of uncertainty, existing beliefs about uncertainty in law and science, and smoking/vaping use patterns that supported the use of uncertainty related to e-cigarettes. Many youth (and some adults) believed that uncertain language enabled audiences to minimize the likelihood of harm or interpreted it as meaning there are both healthy and unhealthy e-cigarettes. This qualitative study provides evidence that the use of types of uncertain language, the frequency of that use, and/or the selection of particular words in warnings, might not achieve the intended public health aims of increasing understanding of risk, deterring youth uptake, and/or facilitating a substantial switch from cigarettes. The use of certain types of uncertain language appears to have significant potential to bring unintended consequences. Suggestions for research and policy are included.

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.

Perceived threat and fear responses to e-cigarette warning label messages: Results from 16 focus groups with U.S. youth and adults

AIMS

A warning on e-cigarette packaging is one way the U.S. government can inform the public of known harms of e-cigarette use. Currently, the only required warning on these products is: "WARNING: This product contains nicotine. Nicotine is an addictive chemical." This exploratory study aims to inform potential future investigations and FDA decisions regarding alternative warnings that may generate fear in addition to being intentionally informational.

METHOD

Data were obtained from responses by 16 online focus groups with adult (N = 47, age range = 18-64) and youth (N = 32, age range 14-16) participants with various smoking and vaping experiences. We showed each focus group a set of hypothetical e-cigarette warning labels to determine how they respond to currently existing public statements that communicate information on the toxicity of ingredients in e-cigarettes, potential health risks, addiction to nicotine, and the uncertainty of the science regarding health effects of using these products. The focus group interviews were audio recorded and transcribed. Transcripts were subjected to a multiphase coding process to identify common response themes. Codes derived from the Extended Parallel Processing Model were then applied to understand impact of potentially fear-inducing language by warning category and age group.

RESULTS

For adults, all warnings-except those about addiction-gave rise to spontaneous danger control (intended) responses, such as quit intentions. Warnings highlighting cognitive and uncertain effects may be particularly promising for adult consumers of tobacco products because both gengerated danger control and response efficacy without evidence of fear control. However, responses also suggest that warnings risk discouraging some adults who use combustible cigarettes from transitioning to e-cigarettes for harm reduction. For youth, while evidence of response efficacy and danger control emerged among youth exposed to messages in all warning categories but one-addiction-unproductive reactions indicative of fear control were also prevalent among youth respondent across most warning types. On average, youth were more skeptical than adults about the harms of using e-cigarettes.

POLICY IMPLICATIONS

Implications of study findings for the development of future effective e-cigarette warning messages are explored.

"They're sleek, stylish and sexy:" selling e-cigarettes online

OBJECTIVE

We examined the product range, marketing strategies, access and marketing claims made by Australian and New Zealand (NZ) online e-cigarette retailers.

METHODS

Twenty Australian (n=10) and NZ (n=10) e-cigarette retail websites were identified via Google using a combination of keywords nominated by an expert panel and identified via a literature review: 'e-cigarette', 'e-cigs', 'vape', and 'vaping', combined with 'Australia', 'AU', 'New Zealand' and 'NZ' and then examined.

RESULTS

Products were extensive (disposable, pod-based, reusable, replacement parts), 95% (n=19) offered 'Starter Kits,' flavoured e-liquid (n=1,032), most containing nicotine (70%, n=14). Most retailers (85%, n=17) offered price discounts and free delivery. There were unsubstantiated health claims (80%, n=16), cessation claims (65%, n=13) and cost-benefit claims (50%, n=10) promoting e-cigarette use. Most (n=14) website age verification features simply required the purchaser to indicate they were aged 18 years.

CONCLUSIONS

Although e-cigarette regulations are different in Australia and NZ, the online product range, marketing strategies, access and marketing claims were similar and sold e-liquid containing nicotine. The health and cessation e-cigarette marketing claims were outlandish and unsubstantiated.

IMPLICATIONS FOR PUBLIC HEALTH

Most purchasing of e-cigarettes occurs online. Regulations and enforcement to limit access and stop unsubstantiated marketing claims must be a public health priority.

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.

Youth and Young Adult-targeted E-cigarette Warnings and Advertising Messages: An Experiment with Young Adults in the US

Warnings specifically focused on harm to younger users have been understudied in vaping warning research, even while vaping products may appeal specifically to a younger population through implicit advertising strategies. This study examined how youth and young adult-focused e-cigarette health warning messages and implicit advertising strategies influence affective responses, risk perceptions, cognitive elaboration about e-cigarette harms, and willingness to vape in the future. We recruited young adults (who, at the time, were not smoking combustible cigarettes) aged 18-25 to participate in an online survey experiment with a 3 (warning label type: current FDA/youth and young adult risk-focused/none) × 3 (advertising health message strategy: explicit/implicit/none) + 3 (non-vaping products control) design. The results show a main effect for warning such that both FDA and targeted warnings increased negative affect and decreased positive affect compared to no warning. Moreover, the youth and young adult-focused warning boosted youth-specific harm beliefs and cognitive elaboration relative to control and the FDA warning, which did not differ from one another. Implicit health messages produced greater positive affect relative to explicit messages and no message, but the ad strategy manipulations did not influence other outcomes. While the population studied here with a single exposure reported no effects of either manipulation on willingness to vape, previous research has associated similar emotions and cognitions with lowered intentions to vape. Regulatory bodies should consider further exploration of vaping warnings that emphasize youth and young adult-specific harms to educate young people about relevant risks.

An Examination Perceptions of Similarity to Cigarettes, Health Risk Perceptions, and Willingness to Try Across Nicotine Vaping Products

INTRODUCTION

This brief report examines how e-cigarette form affects perceptions of cigarette similarity, health risk evaluations, and willingness to try the product. The mediating roles of product form similarity to combustible cigarettes and perceived health risk across vapers and non-vapers are also assessed.

METHODS

A between-subjects experiment examines the effects of four product forms (a cigalike, a vape pen, a tank, and a pod/Juul) for 443 nonsmokers who are either current vapers or non-vapers. Multi-item measures are used to assess the mediating and outcome dependent measures.

RESULTS

Results show that the product form affects similarity, and there are differences between vapers and non-vapers for all outcomes. Moderated mediation results show that (1) form similarity mediates the effects on health perceptions and differs between vapers and non-vapers and (2) there are serial mediation effects of form on willingness to try the different products.

CONCLUSIONS

Electronic nicotine delivery systems (ENDS) product form matters. Similarity to combustible cigarettes influences health risk perceptions, and, in turn, there are effects on willingness to try the product. There are differences in mediation effects across current vapers and non-vapers. These results contribute to understanding reasons why the public health community should monitor and consider how manipulations in product form can affect and reduce health risk perceptions.

IMPLICATIONS

ENDS have evolved since their introduction to the market and are now comprised of product types that vary substantially in design and appearance. By changing form and reducing resemblance to cigarettes, these differences in product form are shown to have downstream consequences on health risk perceptions and willingness to try the product. The public health community needs to consider unconventional ways in which companies may reduce risk perceptions of youthful users and nonusers, even when there are no objective differences in risk across product types.

Visual attention to blu's parody warnings and the FDA's warning on e-cigarette advertisements

OBJECTIVES

In 2017, the e-cigarette brand, blu, released advertisements featuring large, boxed, positively-framed messages. These messages mimicked the format of FDA-mandated warnings that would appear on e-cigarette advertisements in the United States in 2018. We compared attention to blu's parody warnings and FDA-mandated warning appearing on blu advertisements.

METHODS

N = 73 young adults who had used tobacco participated in an eye-tracking study. Participants viewed three blu e-cigarette advertisements in random order: one with a parody warning and two with the FDA-mandated warning (one with a model's face and one without). Areas of interest (AOIs) were the parody or FDA-mandated warning. We compared dwell time on AOIs between the three advertisements.

RESULTS

Participants viewed parody warnings longer than each FDA-mandated warning on average (254 and 608 ms longer; p's < 0.02). Comparing the advertisements with FDA-mandated warnings revealed that participants spent less time looking at the warning in the advertisement with a model's face (354 fewer milliseconds; p = 0.001).

CONCLUSIONS

Parody warnings attracted more visual attention than FDA-mandated warnings, and the presence of a face in the advertisement drew attention away from the FDA-mandated warning. Results underscore the need for advertisement regulations that support increased attention to health warnings.

Associations Between Noticing Nicotine Vaping Product Health Warning Labels, Harm Perceptions, and Use among adult vapers, current and former smokers. Findings From the 2018 ITC Four Country Smoking and Vaping Survey

BACKGROUND

The number of countries mandating a nicotine addiction warning label ('warnings') on nicotine vaping products (NVPs) has been increasing. This study examined associations between noticing NVP warnings, perceptions of NVPs, and intentions to use NVPs.

METHODS

Cross-sectional analysis of 12,619 adult NVP users, cigarette smokers, concurrent users of both cigarettes and NVPs, and quitters who participated in the 2018 International Tobacco Control (ITC) Project Four Country Smoking and Vaping Survey (England, Australia, Canada, US). Logistic regression analyses examined associations between noticing warnings in the past 30 days and perceptions of nicotine harm, NVP harm relative to cigarettes, and NVP addictiveness relative to cigarettes. Associations were also explored between noticing warnings and intentions to use NVPs.

RESULTS

Noticing warnings was higher among NVP users (18.8%) than non-users (2.1%). Noticing warnings was associated with perceiving nicotine to pose little or no harm to health among NVP users, but there was no association among non-users. There was little evidence of an association between noticing warnings and perceptions of NVP harms relative to smoking among NVP users and non-users. Noticing warnings was associated with perceiving NVPs as less addictive than cigarettes among non-users but not NVP users. Among exclusive smokers, noticing warnings was associated with intending to start using NVPs. Among NVP users, there was little evidence of an association between noticing warnings and intentions to continue using/stopping NVPs.

CONCLUSIONS

Noticing NVP warnings was not associated with increased NVP and nicotine harm perceptions or decreased intentions to use NVPs among adult smokers and vapers.

Impact of e-liquid warning labels on young adults' perception of e-cigarettes and intention to use them: an experimental online study

INTRODUCTION

Flavoured e-liquids are especially appealing to young adults. The objective of the present study was to evaluate the effects of text warning labels (WLs) on e-liquid vials used in flavoured electronic cigarettes (e-cigarettes) on e-cigarette non-users' perceptions of harm, addictiveness, emotional valence, interest in trying e-cigarettes and visual attention.

METHODS

Young adults aged 18-25 years (n=313) who were non-e-cigarette users were recruited online and randomised to view images of one of two e-liquid vial conditions (with text WL or without text WL). Each participant was exposed to four images of e-liquid vials. After observing each image, participants reported interest in trying e-cigarettes, emotional valence, perceived harm and addictiveness. Additionally, participants completed an assessment of self-reported visual attention with a priori regions of interest (e-liquid branding and text WL).

RESULTS

Separate two-way Analysis of Variance(ANOVA) that examined the main effects of sex and warning were used for each measure. Text WL on e-liquid vials decreased young adults' intention to use e-cigarettes (especially in men), increased harm perception and decreased appeal to the product. However, they did not influence the perceived addictiveness of e-cigarettes and rarely grabbed attention. Men perceived e-cigarettes as less harmful and less addictive.

CONCLUSIONS

The results suggest that text WLs on e-liquid vials are moderately effective in preventing e-cigarette use in young adults. However, they capture less attention than the rest of the vial and fail to increase the perception of addictiveness. It is suggested to explore other types of design to increase the effectiveness of WLs.

Does the content and source credibility of health and risk messages related to nicotine vaping products have an impact on harm perception and behavioural intentions? A systematic review

AIMS

To systematically review the literature on (i) whether and how various risk messages about nicotine vaping products (NVPs) alter harm perception and behavioural intentions of smokers and non-smokers and (ii) how trust in sources of NVP risk communication affects message reception and behavioural intentions.

METHODS

Seven electronic databases and reference lists of relevant articles were searched for articles published up to April 2020. Experimental and quasi-experimental studies on message effects and cross-sectional studies on source credibility were included. The Newcastle-Ottawa Scale and the Evidence Project Risk of Bias Tool were used to assess the quality of observational and intervention studies, respectively. For each outcome variable, we indicated whether there was an effect (as a 'yes' or 'no') and used effect direction plots to display information on the direction of effects.

RESULTS

Nicotine addiction messages resulted in greater health and addiction risk perceptions, relative risk messages comparing the health risks of NVPs to cigarette smoking increased the perception that NVPs are less harmful than combustible cigarettes, and a nicotine fact sheet corrected misperceptions of nicotine and NVPs. Smokers' intention to purchase, try or switch to NVPs was higher when exposed to a relative risk message and lower when exposed to nicotine addiction warnings. Trust in NVP risk information from public health agencies was associated with lower odds of; (i) NVP use and (ii) perceiving NVPs as less harmful, whereas those who trusted information from NVP companies were more likely to perceive NVPs as less harmful than combustible cigarettes.

CONCLUSIONS

Relative risk messages may help improve the accuracy of harm perceptions of nicotine vaping products and increase smokers' intentions to quit smoking and/or to switch to vaping, although the literature is nascent.

Mobile Text Messaging for Tobacco Risk Communication Among Young Adult Community College Students: Randomized Trial of Project Debunk

BACKGROUND

The use of new and emerging tobacco products (NETPs) and conventional tobacco products (CTPs) has been linked to several alarming medical conditions among young adults (YAs). Considering that 96% of YAs own mobile phones, SMS text messaging may be an effective strategy for tobacco risk communication.

OBJECTIVE

Project Debunk is a community-based randomized trial aiming to identify specific types of messages that effectively improve perceived NETP and CTP risk among YAs in community colleges.

METHODS

With YAs recruited offline from 3 campuses at the Houston Community College (September 2016 to July 2017), we conducted a 6-month randomized trial with 8 arms based on the combination of 3 message categories: framing (gain-framed vs loss-framed), depth (simple vs complex), and appeal (emotional vs rational). Participants received fully automated web-based SMS text messages in two 30-day campaigns (2 messages per day). We conducted repeated-measures mixed-effect models stratified by message type received, predicting perceived CTP and NETP risks. Owing to multiple testing with 7 models, an association was deemed significant for P<.007 (.05 divided by 7).

RESULTS

A total of 636 participants completed the baseline survey, were randomized to 1 of 8 conditions (between 73 and 86 participants per condition), and received messages from both campaigns. By the 2-month post campaign 2 assessment point, 70.1% (446/636) completed all outcome measures. By the end of both campaigns, participants had a significant increase in perceived NETP risk over time (P<.001); however, participants had a marginal increase in perceived CTP risk (P=.008). Separately for each group, there was a significant increase in perceived NETP risk among participants who received rational messages (P=.005), those who received emotional messages (P=.006), those who received simple messages (P=.003), and those who received gain-framed messages (P=.003).

CONCLUSIONS

In this trial, YAs had an increase in perceived NETP risk. However, with stratification, we observed a significant increase in perceived NETP risk upon exposure to rational, emotional, simple, and gain-framed messages. In addition, YAs generally had an increase in perceived CTP risk and presented nonsignificant but observable improvement upon exposure to emotional, complex, and loss-framed messages. With the results of this study, researchers and practitioners implementing mobile health programs may take advantage of our tailored messages through larger technology-based programs such as smartphone apps and social media campaigns.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03457480; https://clinicaltrials.gov/ct2/show/NCT03457480.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/10977.

Effective package warning label systems for communicating relative risks of cigarettes, heated tobacco products, and e-cigarettes: An experimental study with Korean adults

BACKGROUND

Warning labels are a fundamental public health strategy for communicating about tobacco product risks, but effective warning labels for heated tobacco products (HTPs) and e-cigarettes (ECs) are yet to be determined. We examined the effect of two warning label systems for communicating the relative risks of using cigarettes, HTPs, and ECs.

METHODS

1,280 Korean adults were recruited from an online commercial panel, including susceptible non-users of cigarettes, HTPs, or ECs aged 19 to 29 (n = 444) and current users of these tobacco products aged 19 or older (n = 836). Participants viewed packages for cigarettes, HTPs, and ECs in a 2 × 2 between-subject experiment: "dashboard" icons integrated into warnings vs. no dashboard; different-sized warnings (70% of cigarette packages, 50% of HTP packs, 30% of EC packages) vs. current equal-sized warnings (50% of cigarette/HTP/EC packages).

RESULTS

Participants exposed to the dashboard warning system were more likely than those who were not to report higher perceived harm of cigarettes than ECs, cigarettes than HTPs, and HTPs than ECs, as well as perceived benefit of switching from cigarettes to HTPs, cigarettes to ECs, and HTPs to ECs. Participants exposed to the different-sized warning system did not report differences in perceived relative harm or benefit compared to those who were not, and no interaction of dashboard warnings with warning sizes was found.

CONCLUSION

The use of dashboard icons with texts and colors representing different levels of risk may promote public understanding about the continuum of risk across tobacco products.

Development and testing of relative risk-based health messages for electronic cigarette products

BACKGROUND

Health messages on e-cigarette packs emphasise nicotine addiction or harms using similar wording to warnings on cigarette packs. These may not be appropriate for e-cigarettes which constitute a reduced risk alternative for smokers. This research aimed to (1) develop and test a selection of relative risk messages for e-cigarette products; (2) compare these to the two current EU Tobacco Products Directive (TPD) nicotine addiction messages; and (3) explore differences between smokers, non-smokers and dual users.

METHOD

Twenty-six messages focusing on either harm-reduction or cessation were developed and rated by multidisciplinary experts for accuracy, persuasiveness and clarity. The eight highest ranking messages were compared alongside the TPD messages in a sample of 983 European residents (316 smokers, 327 non-smokers, 340 dual users) on understandability, believability and convincingness.

RESULTS

On all three constructs combined, the two TPD messages rated the highest, closely followed by four relative risk messages "Completely switching to e-cigarettes lowers your risk of smoking related diseases", "Use of this product is much less harmful than smoking", "Completely switching to e-cigarettes is a healthier alternative to smoking", and "This product presents substantially lower risks to health than cigarettes" which did not differ statistically from the TPD messages. Non-smokers rated TPD1 significantly higher overall than dual users. Dual users rated "This product is a safer alternative to smoking" significantly higher than non-smokers. Messages did not differ on understandability.

CONCLUSIONS

These alternative messages provide a useful resource for future research and for policy makers considering updating e-cigarette product labelling.

Characterization of Electronic Cigarette Warning Statements Portrayed in YouTube Videos

INTRODUCTION

In 2018, the United States Food and Drug Administration (FDA) required that electronic cigarette (e-cigarette) manufacturers, packagers, importers, distributors, and retailers display an addictive or alternate warning statement on e-cigarette visual advertisements. Few studies have investigated the FDA-mandated and other warnings on social media. This study examined the prevalence and content of warning statements in e-cigarette-related YouTube videos.

METHODS

In 2019, The Virginia Commonwealth University Center for the Study of Tobacco Products conducted bi-monthly (February-June) YouTube searches by relevance and view count to identify e-cigarette-related videos. Overall, 178 videos met the inclusion criteria. Staff coded each video for the presence of a visual/verbal warning statement, warning statement type (eg, FDA-mandated, addiction/tobacco, safety/toxic exposure, health effects), sponsorship, and tobacco product characteristics. A data extraction tool collected the video URL, title, upload date, and number of views, likes/dislikes, and comments.

RESULTS

Only 5.1% of videos contained FDA-mandated and 21.9% contained non-mandated warnings. All videos with FDA-mandated and 46.2% of non-mandated warnings were represented visually. Only 13.1% of industry-sponsored videos uploaded after the mandate effective date had an FDA-mandated warning statement and videos with FDA-mandated and non-mandated (v. no) warnings had significantly fewer views, likes, dislikes, and comments. Among all non-mandated warnings, 31.3% featured an addiction/tobacco, 18.8% a safety/toxic exposure, and 37.5% a health effects warning.

CONCLUSIONS

The prevalence of FDA-mandated warning statements in e-cigarette related YouTube videos was low. FDA enforcement of the warning statement mandate on YouTube could increase the public's understanding of the addictive nature of nicotine in e-cigarettes.

IMPLICATIONS

The FDA has the authority to regulate the advertisement and promotion of e-cigarettes on the Internet. These data can inform future FDA requirements related to the language content and visual representation of addiction/tobacco, safety/exposure, and health effects warning statements that appear in YouTube videos and other visual social media popular among young people. Such data would help consumers make informed decisions about purchasing e-cigarette products, using e-cigarettes, and avoiding unintentional harm related to e-cigarettes. In addition, these data may help social media platforms make decisions on whether they will prohibit advertisements that promote or facilitate the sale of tobacco products.

Communicating risk differences between electronic and combusted cigarettes: the role of the FDA-mandated addiction warning and a nicotine fact sheet

INTRODUCTION

The US Food and Drug Administration requires e-cigarettes to carry a nicotine addiction warning. This research compared the effects of messages communicating comparative risk of electronic and combusted cigarettes (CR messages) with and without the mandated warning and tested the effects of showing a nicotine fact sheet (NFS) before exposure to CR messages with warning.

METHOD

In an online experiment, 1528 US adult smokers were randomised to one of four conditions: (1) three CR messages, (2) three CR messages in condition one with an addiction warning, (3) an NFS followed by the three messages in condition 2 and (4) control messages. Outcomes included message reactions and perceived effectiveness, e-cigarette-related and cigarette-related beliefs and behavioural intentions and nicotine-related beliefs.

RESULTS

CR messages with and without an addiction warning did not differ. The NFS condition produced higher odds of correctly understanding the risk of nicotine and stronger beliefs that switching to e-cigarettes could reduce health risks (response efficacy) than other treatments. Compared with control, all messages made it more likely for people to report e-cigarettes are less harmful than cigarettes and increased response efficacy and switch intentions to e-cigarettes. Only NFS condition increased correct beliefs about the risk of nicotine and self-efficacy about switching to e-cigarettes.

CONCLUSION

Including an addiction warning on CR messages did not reduce intentions to switch to e-cigarettes. Communicating accurate risk of nicotine together with CR messages and addiction warning increased smokers' self-efficacy beliefs about switching completely to e-cigarettes, making it a potentially promising antitobacco communication strategy.

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

INTRODUCTION

Effective August 2018, the U.S. Food and Drug Administration (FDA) required that nicotine addiction warnings be placed on ads for nicotine containing e-liquids. As per FDA comments, this provision pertains to visual ads communicated via social media, raising questions about compliance within the large e-liquid promotion community on Instagram.

AIMS AND METHODS

This study examines use of warnings on promotional Instagram posts before and after provisions took effect on August 10, 2018. Netlytic was used to gather a sample of 500 promotional #eliquid and #ejuice posts from: May 2017, October 2017, March 2018, August 2018, and September 2018. The 1500 prewarning and 1000 postwarning posts were coded using content analysis. Changes in products and marketing strategies were also considered. Post volume was tracked monthly between May 2017 and February 2020.

RESULTS

In the prewarning period, nicotine warning statements were absent on all posts. Following August 10, 2018, FDA compliant warnings were present on 13.6% of posts. Among US-based posts, 36.4% used the warnings, with warnings more common on posts made by e-liquid brands (52.3%) and posts promoting e-liquids with nicotine (40.0%). Promotional strategies and products did not significantly change. The share of posts made by US Instagram users decreased by 11%, although total post volume continued to grow.

CONCLUSIONS

Many e-liquid promotion posts on Instagram remained noncompliant with nicotine warnings after FDA provisions took effect. The large volume of international users also limited the impact of FDA-mandated warnings on the social media environment.

IMPLICATIONS

Further guidance and enforcement are needed to ensure that US e-liquid marketers on visual social media platforms adhere to current provisions, particularly for individual social media users who are sponsored by industry. The inherently global span of social media also indicates the importance of a shared approach to marketing regulations. Further work is needed to assess enforcement strategies viable for the social media environment.

An Experimental Study of Nicotine Warning Statements in E-cigarette Tweets

INTRODUCTION

It is unclear whether warnings on electronic cigarette (e-cigarette) advertisements required by the US Food and Drug Administration (FDA) will apply to social media. Given the key role of social media in marketing e-cigarettes, we seek to inform FDA decision making by exploring how warnings on various tweet content influence perceived healthiness, nicotine harm, likelihood to try e-cigarettes, and warning recall.

METHODS

In this 2 × 4 between-subjects experiment participants viewed a tweet from a fictitious e-cigarette brand. Four tweet content versions (e-cigarette product, e-cigarette use, e-cigarette in social context, unrelated content) were crossed with two warning versions (absent, present). Adult e-cigarette users (N = 994) were recruited via social media ads to complete a survey and randomized to view one of eight tweets. Multivariable regressions explored effects of tweet content and warning on perceived healthiness, perceived harm, and likelihood to try e-cigarettes, and tweet content on warning recall. Covariates were tobacco and social media use and demographics.

RESULTS

Tweets with warnings elicited more negative health perceptions of the e-cigarette brand than tweets without warnings (p < .05). Tweets featuring e-cigarette products (p < .05) or use (p < .001) elicited higher warning recall than tweets featuring unrelated content.

CONCLUSIONS

This is the first study to examine warning effects on perceptions of e-cigarette social media marketing. Warnings led to more negative e-cigarette health perceptions, but no effect on perceived nicotine harm or likelihood to try e-cigarettes. There were differences in warning recall by tweet content. Research should explore how varying warning content (text, size, placement) on tweets from e-cigarette brands influences health risk perceptions.

IMPLICATIONS

FDA's 2016 ruling requires warnings on advertisements for nicotine-containing e-cigarettes, but does not specify whether this applies to social media. This study is the first to examine how e-cigarette warnings in tweets influence perceived healthiness and harm of e-cigarettes, which is important because e-cigarette brands are voluntarily including warnings on Twitter and Instagram. Warnings influenced perceived healthiness of the e-cigarette brand, but not perceived nicotine harm or likelihood to try e-cigarettes. We also saw higher recall of warning statements for tweets featuring e-cigarettes. Findings suggest that expanding warning requirements to e-cigarette social media marketing warrants further exploration and FDA consideration.

Communicating the relative health risks of E-cigarettes: An online experimental study exploring the effects of a comparative health message versus the EU nicotine addiction warnings on smokers' and non-smokers' risk perceptions and behavioural intentions

INTRODUCTION

This study investigated the effects of the European Union Tobacco Products Directive [EU-TPD] Article 20 E-cigarette (EC) health warnings ("This product contains nicotine which is a highly addictive substance. [It is not recommended for non-smokers.]") and a comparative harm message ("Use of this product is much less harmful than smoking" [COMP]) on smokers' and non-smokers' perceptions and behavioural intentions.

METHODS

2495 UK residents (1283 smokers and 1212 non-smokers) self-reported perceived harm, addictiveness, EC effectiveness, social acceptability, and intentions to purchase and use EC, and in smokers, intentions to quit and intentions to use EC in future quit attempts. These were measured before and after exposure to EC images containing either the TPD, COMP, TPD + COMP or no message.

RESULTS

Non-smokers had higher harm, addictiveness and lower social acceptability perceptions. TPD presence increased, whilst COMP decreased, harm and addictiveness perceptions in both groups. For smokers only, harm perceptions were lower following exposure to COMP alone vs. no message. For non-smokers the TPD increased harm perceptions vs. no message. There were no effects on social acceptability, EC effectiveness or use intentions. In smokers only, purchase and quit intentions were higher following exposure to the COMP alone.

CONCLUSION

TPD messages may be effective smoking prevention tools, although the COMP message was more effective in reducing harm perceptions and increasing use intentions in smokers. That COMP did not increase use intentions in non-smokers suggest that such exposures may potentially act as an effective harm reduction tool without resulting in increased uptake among non-smokers.

E-Cigarette Marketing and Communication: How E-Cigarette Companies Market E-Cigarettes and the Public Engages with E-cigarette Information

Introduction

Given the lack of regulation on marketing of electronic cigarettes (e-cigarettes) in the United States and the increasing exchange of e-cigarette-related information online, it is critical to understand how e-cigarette companies market e-cigarettes and how the public engages with e-cigarette information.

Methods

Results are from a systematic review of peer-reviewed literature on e-cigarettes via a PubMed search through June 1, 2017. Search terms included: "e-cigarette*" or "electronic cigarette" or "electronic cigarettes" or "electronic nicotine delivery" or "vape" or "vaping." Experimental studies, quasi-experimental studies, observational studies, qualitative studies, and mixed methods studies providing empirical findings on e-cigarette marketing and communication (ie, nonmarketing communication in the public) were included.

Results

One hundred twenty-four publications on e-cigarette marketing and communication were identified. They covered topics including e-cigarette advertisement claims/promotions and exposure/receptivity, the effect of e-cigarette advertisements on e-cigarette and cigarette use, public engagement with e-cigarette information, and the public's portrayal of e-cigarettes. Studies show increases in e-cigarette marketing expenditures and online engagement through social media over time, that e-cigarettes are often framed as an alternative to combustible cigarettes, and that e-cigarette advertisement exposure may be associated with e-cigarette trial in adolescents and young adults.

Discussion

Few studies examine the effects of e-cigarette marketing on perceptions and e-cigarette and cigarette use. Evidence suggests that exposure to e-cigarette advertisements affects perceptions and trial of e-cigarettes, but there is no evidence that exposure affects cigarette use. No studies examined how exposure to e-cigarette communication, particularly misleading or inaccurate information, impacts e-cigarette, and tobacco use behaviors.

Implications

The present article provides a comprehensive review of e-cigarette marketing and how the public engages with e-cigarette information. Studies suggest an association between exposure to e-cigarette marketing and lower harm perceptions of e-cigarettes, intention to use e-cigarettes, and e-cigarette trial, highlighting the need to for advertising regulations that support public health goals. Findings from this review also present the methodological limitations of the existing research (primarily due to cross-sectional and correlational analyses) and underscore the need for timely, rigorous research to provide an accurate understanding of e-cigarette marketing and communication and its impact on e-cigarette and tobacco product use.

E-cigarette Product Preferences among Adult Smokers: A Discrete Choice Experiment

OBJECTIVES

In this study, we used a discrete choice experiment (DCE) conducted August-October 2017 to examine electronic nicotine delivery systems (ENDS) product preferences in a national sample of adult smokers (N = 1154) who were also using ENDS or had not ruled out future use.

METHODS

The DCE evaluated 5 ENDS attributes: relative harm; effectiveness for helping smokers quit; nicotine strength; flavor; and price. We asked participants to choose among their own cigarettes, 2 ENDS products whose attributes varied across tasks, or none. We analyzed ENDS preferences using multinomial, nested, and mixed logit regressions.

RESULTS

Smokers preferred ENDS that are less harmful than cigarettes, are effective in helping smokers quit, are lower priced, and are not menthol-flavored. The marginal willingness to pay for an ENDS product was $8.40 when less harmful than cigarettes, $4.13 when of unknown effectiveness in helping quitting ($13.90 when effective), and $3.37 when ENDS are not menthol-flavored. Furthermore, the overall flavor preference is driven by tobacco smokers, not by menthol cigarette smokers who do prefer menthol-flavored ENDS.

CONCLUSIONS

Policies that affect perceptions of ENDS effectiveness in promoting cessation and their relative harm may alter smokers' ENDS preferences. Regulating flavors and price also may influence adult smokers' ENDS preference.

Exposure to and perceptions of health warning labels on nicotine vaping products: findings from the 2016 International Tobacco Control Four Country Smoking and Vaping Survey

BACKGROUND AND AIMS

The presence and content of health warning labels (HWLs) on nicotine vaping products (NVPs), such as electronic cigarettes, varies by country and manufacturer. We compared proportions of people who report (i) noticing HWLs on NVPs and (ii) feeling concerned having noticed HWLs, by country and by smoking or vaping status. We also examined recall of HWL content and whether this varies by country.

DESIGN

Cross-sectional survey.

SETTING

Australia (AU), Canada (CA), England (EN) and the United States (US). At the time of data collection, HWLs on NVPs were only mandatory in EN.

PARTICIPANTS

A total of 11 561 respondents from the following samples in the 2016 International Tobacco Control Four Country Project: (1) re-contacted smokers and quitters who had participated in the previous wave of the project; (2) newly recruited current smokers and recent quitters; and (3) newly recruited current vapers from CA, EN and US.

MEASUREMENTS

Outcomes included: (1) having noticed HWLs on NVPs, (2) feeling concerned having noticed HWLs, and (3) recall of HWL message content.

FINDINGS

Compared with respondents in EN, respondents in CA were more likely to report having noticed HWLs [odds ratio (OR) = 1.58, P = 0.02], whereas respondents in AU (OR = 0.76, P = 1.00) and the US (OR = 1.54, P = 0.09) were not significantly more or less likely to report having noticed HWLs. Compared with concurrent smokers and vapers, daily smokers, non-daily smokers and quitters were less likely to report having noticed HWLs (ORs = 0.21, 0.33 and 0.19, respectively, all P < 0.001). There were no significant differences in reports of noticing HWLs when comparing concurrent smokers and vapers with daily (OR = 1.62, P = 0.91) or non-daily (OR = 1.15, P = 1.00) vapers. There were no significant differences by country in reporting that HWLs made them concerned about using NVPs. Daily vapers were less likely to report feeling concerned than concurrent users (OR = 0.11, P = 0.017). Among those who reported reading HWLs (n = 688), there was little evidence of differences in recall of the HWL content.

CONCLUSIONS

Respondents in England, where health warning labels on nicotine vaping products are mandatory, were not significantly more likely to report having noticed such warnings than those in Australia, Canada and the United States where warnings are not mandatory.

Baseline assessment of noticing e-cigarette health warnings among youth and young adults in the United States, Canada and England, and associations with harm perceptions, nicotine awareness and warning recall

Health warnings on tobacco products can inform users of potential risks. However, little is known about young people's exposure to health warnings on e-cigarette products. This baseline assessment of young people's noticing e-cigarette warnings uses nationally representative data from three countries.

Data were collected under Wave 1 of the ITC Youth Tobacco and E-cigarette Survey, conducted in Canada, England, and the US. Online surveys were completed by 16–19-year-olds in July/August 2017 (n = 12,064), when warnings were either newly required (England) or voluntarily carried by some manufacturers (US, Canada). Analyses examined prevalence and correlates of noticing warnings and associations between noticing warnings and product perceptions, adjusting for country, sex, age, race/ethnicity, and cigarette/e-cigarette use status.

About 12% reported noticing warnings on e-cigarette packaging in the past 30 days. Noticing warnings was significantly more likely among youth in England (AOR = 1.3, p < .01) and the US (AOR = 1.3, p < .01) versus Canada, and was most likely among dual e-cigarette/cigarette users (AOR = 4.69, p < .001) versus nonusers. Unaided recall of the keyword “nicotine” was low among those who noticed warnings (7.5%). However, ever e-cigarette users who noticed warnings had higher odds of knowing whether e-cigarettes contained nicotine (AOR = 2.26, p < .001). Noticing warnings was significantly associated with higher odds of believing e-cigarettes cause at least some harm to users (AOR = 1.19), are as harmful as cigarettes (AOR = 1.45), and can be addictive (AOR = 1.43).

Baseline assessment reveals that youth's noticing of e-cigarette warnings and recall of nicotine-addiction messages was low. Research should track exposure over time as warning requirements are implemented across different countries.

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Noticing warnings on e-cig products is low in the US, England and Canada.

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Ever users: noticing warnings had higher odds of not knowing e-cigs have nicotine.

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Noticing warnings associated with higher odds of believing e-cigs can be addictive

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Exposure should be tracked over time as warnings are implemented across countries.

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Exposure to e-cig warnings may influence harm perceptions and use intentions.

Adolescents' receptivity to E-cigarette harms messages delivered using text messaging

INTRODUCTION

E-cigarette use among adolescents has dramatically risen since 2011, yet little research has tested e-cigarette harms messages among adolescents. We conducted a pretest-posttest pilot study to examine adolescents' receptivity to e-cigarette health harms messages delivered using text messaging.

METHODS

N = 69 adolescents were enrolled in an 8-day pretest-posttest text messaging study. Participants completed a pretest survey on day one, were texted one of three e-cigarette health harms messages per day on days two through seven, and completed a posttest survey on day eight (88% retention). We assessed message ratings at posttest and knowledge, thoughts, and beliefs about e-cigarette harms at pretest and posttest.

RESULTS

Adolescents rated the three messages favorably, with both the chemical and brain messages scoring higher than the nicotine message on fear arousal and perceived message effectiveness. More than one-third of adolescents showed the messages to others and talked to others about the messages. At posttest, knowledge about the harms of e-cigarettes, thinking about the risks of e-cigarettes, and perceived risks of e-cigarettes were all significantly higher compared to pretest (p < .05). Participants largely adhered to the text messaging protocol and found the study highly acceptable.

CONCLUSIONS

This pilot study suggests that adolescents are receptive to e-cigarette health harms messages and that delivering such messages using text messaging is feasible and acceptable. Future research should systematically develop and test a broad set of e-cigarette health harms messages and examine their impact in a randomized controlled trial.

The Impact of E-Cigarette Warnings, Warning Themes and Inclusion of Relative Harm Statements on Young Adults' E-Cigarette Perceptions and Use Intentions

Although e-cigarettes in the United States are required to carry one nicotine addiction warning, little is known about the impact of other potential e-cigarette warning themes, nor about pairing warnings with messages that communicate e-cigarettes' reduced-harm potential relative to cigarettes. We randomly assigned 876 young adults (ages 18⁻29) to view e-cigarette ads in a 3 × 2 plus control online experiment that varied by warning theme (i.e., nicotine addiction; nicotine's impact on adolescent brain development; presence of harmful chemicals) and warning type-i.e., the presence ("relative harm warning") or absence ("standard warning") of a relative harm (RH) statement in the warning label ("e-cigarettes may cause harm to health but are less harmful than cigarettes"). Warning believability, informativeness, understandability and support were high across conditions and there were no significant differences by warning theme on e-cigarette harm perceptions or use intentions nor on nicotine (mis)perceptions. Perceived warning effectiveness for discouraging youth initiation was higher for the "brain" and "chemicals" warnings compared to the addiction warning. Warnings with the included RH statement were perceived as less believable and credible and were less frequently correctly recalled. Research should continue to investigate the impact of different e-cigarette warning themes and formats with priority audiences.

Messages matter: The Tobacco Products Directive nicotine addiction health warning versus an alternative relative risk message on smokers' willingness to use and purchase an electronic cigarette

INTRODUCTION

Many countries have now mandated warning labels on e-cigarette products. One example, the EU TPD health warning states, "This product contains nicotine which is a highly addictive substance. [It is not recommended for use by non-smokers]". The impact of the EU TPD warning message on intentions to use, has not been explored within an EU population.

AIMS

Examine the effect of i) the TPD e-cigarette health warning and ii) an alternative relative risk message, on smokers' willingness to use, likelihood of purchase, and intention to use as a quit aid.

METHODS

Cross-sectional online study. Ninety-five smokers (55 males; 18-55 years old) were randomly allocated to one of three conditions and viewed ten individually presented e-cigarettes images with either no message, TPD message, or relative risk message. Participants rated i) willingness to use, and likelihood of: ii) purchase, iii) using in the next month, and iv) using in a quit attempt, before and after viewing the images.

RESULTS

For willingness to use and likelihood of purchase, ANCOVAs showed a significant main effect of Message Type (ps, <.05); ratings were lower in the TPD condition. Message type, however did not significantly change likelihood of using in the next month or using in a quit attempt.

CONCLUSIONS

Preliminary findings suggest that the TPD e-cigarette health warning may reduce smokers' willingness to use and likelihood of purchasing an e-cigarette. Messages conveying reduced harm or indeed, no message at all, may be more effective in encouraging smokers to switch to these lower risk products.

The effects of the European e-cigarette health warnings and comparative health messages on non-smokers' and smokers' risk perceptions and behavioural intentions

BACKGROUND

Article 20 of the EU Tobacco Products Directive [TPD] stipulates that e-cigarette packets and refill products must carry a nicotine addiction health warning. Although previous studies conducted in North America have found that perceived harm, addictiveness and intention to use declined following exposure to e-cigarette health warnings, possible effects of the TPD health warnings on smokers and non-smokers has not been studied. This study will investigate the effects of the EU TPD e-cigarette health warnings and a comparative harm message (COMP; developed specifically for this study) on smokers' and non-smokers' perceptions of harm, addictiveness and social acceptability of e-cigarettes. Additionally, the potential effects of the TPD warnings and the COMP on smokers' intentions to purchase and use e-cigarettes will be explored.

METHODS/DESIGN

A sample of 2400 UK residents will be recruited in this experimental, randomised design, with Smoking status (Smoker vs. Non-smoker), TPD presence (TPD1 vs. TPD2 vs. No-TPD) and COMP presence (Presence vs. Absence) as between subjects independent variables, and Time (pre-post exposure of images) as a within subjects factor. Dependent variables comprise self-reported perceived harm, addictiveness, social acceptability, e-cigarettes' effectiveness, intentions to purchase and use e-cigarettes. Cigarette dependence, previous e-cigarette exposure, and baseline intentions to quit will be measured as covariates.

DISCUSSION

Health warnings, such as those implemented by the TPD, may help to prevent non-smokers from e-cigarettes use, but it is possible that they may inadvertently deter smokers from initiating use and substituting their tobacco smoking for e-cigarettes use if their content is deemed too negative. It is hoped that this study will help identify the most effective message or combination of messages that encourage use among smokers without promoting use among non-smokers.

TRIAL REGISTRATION

ISRCTN registry ISRCTN76967031 ; date of registration: 23/10/18.

The Association between Potential Exposure to Magazine Ads with Voluntary Health Warnings and the Perceived Harmfulness of Electronic Nicotine Delivery Systems (ENDS)

(1) Background: Several brands of electronic nicotine delivery systems (ENDS) carry voluntary health warning messages. This study examined how potential exposure to ENDS magazine ads with these voluntary health warnings were associated with the perceived harmfulness of ENDS. (2) Methods: Risk perception measures and self-reported exposure to ENDS ads were obtained from the 2014 Georgia State University (GSU) Tobacco Products and Risk Perceptions Survey of a nationally representative sample of U.S. adults. We examined the association between potential exposure to magazine ads with warnings and the perceived harms of ENDS relative to cigarettes, using binary logistic regressions and controlling for general ENDS ad exposure and socio-demographic characteristics. (3) Results: Potential exposure to ENDS magazine ads with warnings was associated with a lower probability of considering ENDS to be more or equally harmful compared to cigarettes, particularly among non-smokers (OR = 0.16; 95% CI: 0.04–0.77). In addition, ad exposure, ENDS use history, race/ethnicity, gender, education, and income were also associated with harm perceptions. (4) Conclusions: This study did not find evidence that magazine ads with warnings increased misperceptions that ENDS are equally or more harmful than cigarettes. With more ENDS advertisements carrying warnings, more research is needed to determine how the warnings in advertisements convey relative harm information to consumers and the public.

Validation of mobile phone text messages for nicotine and tobacco risk communication among college students: A content analysis

INTRODUCTION

In the United States, young adults have the highest prevalence of tobacco use. The dissemination of mobile phone text messages is a growing strategy for tobacco risk communication among young adults. However, little has been done concerning the design and validation of such text messages. The Texas Tobacco Center of Regulatory Science (Texas-TCORS) has developed a library of messages based on framing (gain- or loss-framed), depth (simple or complex) and appeal (emotional or rational). This study validated the library based on depth and appeal, identified text messages that may need improvement, and explored new themes.

METHODS

The library formed the study sample (N=976 messages). The Linguistic Inquiry and Word Count (LIWC) software of 2015 was used to code for word count, word length and frequency of emotional and cognitive words. Analyses of variance, logistic regression and scatter plots were conducted for validation.

RESULTS

In all, 874 messages agreed with LIWC-coding. Several messages did not agree with LIWC. Ten messages designed to be complex indicated simplicity, while 51 messages designed to be rational exhibited no cognitive words. New relevant themes were identified, such as health (e.g. ‘diagnosis’, ‘cancer’), death (e.g. ‘dead’, ‘lethal’) and social connotations (e.g. ‘parents’, ‘friends’).

CONCLUSIONS

Nicotine and tobacco researchers can safely use, for young adults, messages from the Texas-TCORS library to convey information in the intended style. Future work may expand upon the new themes. Findings will be utilized to develop new campaigns, so that risks of nicotine and tobacco products can be widely disseminated.

Considerations and Future Research Directions for E-Cigarette Warnings-Findings from Expert Interviews

Tobacco warning labels are important sources of risk information but research historically has been cigarette-centric. This qualitative study aimed to inform future direction and research on warnings for e-cigarettes. Between June and August 2016, we conducted interviews with 10 researchers with expertise in tobacco warning label research. Interviewees were registrants of a 2016 National Cancer Institute grantee meeting on tobacco warnings. Several participants agreed that the Food and Drug Administration's new nicotine addiction warning for e-cigarettes could be informative but that it might not resonate with young people. Many agreed that more than one warning would be important as e-cigarette science evolves and that research on additional warning themes (e.g., nicotine exposure, harmful constituents) and execution styles (including use of pictorials) was important. Participants were somewhat mixed about the use of reduced-risk messages within e-cigarette warnings, but agreed that research on how to communicate about cigarette/e-cigarette relative risks was needed. Overall, more research is needed on tobacco warnings for non-cigarette products, including on the message content, placement, execution and potential impact on audiences' product knowledge, risk perceptions and use intentions. This is particularly needed for products such as e-cigarettes which may have harm-reduction potential relative to cigarettes and require unique considerations.