Noticing Voluntary E-Cigarette Warning Labels and Associations With Harm Perceptions and Use Intentions: A Baseline Cross-Sectional Analysis of Wave 4 of the Population Assessment of Tobacco and Health Study Prior to the Food and Drug Administration Mandate

PURPOSE

To examine the effect of e-cigarette warning labels (EWLs) prior to the August 2018 FDA-warning label mandate to establish a baseline for future research.

DESIGN

Cross-sectional survey.

SETTING

United States.

PARTICIPANTS

A cohort of adult participants in the Population Assessment of Tobacco and Health (PATH) study (n = 30,004) at Wave 4 (Dec 2016-Jan 2018).

MEASURES

Correlates (e.g., sociodemographics, substance use, social influence, cigarette warnings, and mental health) of noticing EWLs in the past 30-days (noticed vs did not notice), perceived harm of e-cigarettes/nicotine (from 1 = not at all harmful to 5 = extremely harmful), relative harm of e-cigarettes (from 1 = less harmful to 3 = more harmful than cigarettes), intention to quit (yes/no) and intention to try e-cigarettes (from 1 = definitely not to 4 = definitely yes).

RESULTS

The prevalence of noticing EWLs was 22.1%. Those who currently use electronic nicotine products, established and experimentally, were more likely to notice EWLs relative to never users (aOR = 3.55; 95% CI: 2.96-4.25; P < .001 and aOR = 2.42; 95% CI: 1.88-3.10; P < .001, respectively). Those with past 30-day alcohol and cigarette use were less likely to notice EWLs (aOR = .27; 95% CI: .24-.31 and aOR = .91; 95% CI: .83-.99; respectively). Those who noticed cigarette warnings were more likely to notice EWLs (aOR = 12.00; 95% CI: 10.46-13.77; P < .001). Among those who noticed EWLs, there were higher odds of perceiving e-cigarettes to be equally or more harmful than cigarettes (aOR = 1.15; 95% CI: 1.02-1.30), but no association was found between noticing EWLs and perceived harm of e-cigarettes/nicotine or use intentions.

CONCLUSION

Noticing voluntary EWLs was not associated with increased perceived harm of e-cigarettes and nicotine harm, or e-cigarette use intentions. Future research is warranted to examine the effect of the FDA mandated EWLs.

Identifying promising themes and messages for youth vaping prevention: A national study

Use of e-cigarettes and vapes among adolescents continues to be a major public health concern. Health communication efforts can discourage e-cigarette use among adolescents by influencing beliefs and behavior. However, to do so, studies need to identify the most promising themes and messages based on the latest evidence about the harms of e-cigarettes and vaping. Participants were a nationally representative sample of 1,603 US adolescents aged 13-17 years, recruited in the summer of 2022. Adolescents were randomly assigned to view 7 vaping prevention statements (one from each theme: nicotine addiction, chemical harms, health symptoms, mental health, organ effects, cosmetic effects, and monetary cost) and 1 control statement (vape litter theme) from a pool of 46 statements that were developed through a systematic process. Participants rated each statement on perceived message effectiveness (PME), awareness, and believability. Results of linear mixed models indicated that all vaping prevention themes out-performed control messages on PME, with chemical harms and organ effects having the largest effects, followed by nicotine addiction and then other themes. For most message themes, PME effects were stronger for youth susceptible to vaping compared to non-susceptible youth and users. Both awareness and believability predicted higher levels of PME. In secondary analyses, we found that statements specifying the target ("you") and longer statements were also rated higher on PME. Results suggests that the most potent vaping prevention messages for adolescents are those that focus on vape chemicals and the potential of vaping to damage organs and increase disease risk.

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.

Health warning labels on heated tobacco products and their impact on use intentions and risk perceptions: a cross-sectional study of adult tobacco users in the US and Israel

BACKGROUND

Health warning labels (HWLs) represent an evidence-based tobacco control strategy; however, their application to heated tobacco products (HTPs) and related impacts are understudied. This study examined the impact of HTP HWLs on HTP use intentions and risk perceptions among current tobacco users.

METHODS

We analyzed cross-sectional survey data from adults in the US and Israel reporting past-month tobacco use and awareness of HTPs (N = 424). Multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of HTP HWLs (i.e., more concerned about HTP use, reassured, no effect [referent]) among those who noticed HTP HWLs (multinomial regressions); and (2) HWL impacts in relation to HTP use intentions and perceived addictiveness and harm (linear regressions).

RESULTS

Among participants who noticed HTP HWLs (n = 372, 87.7%), 27.7% reported HWLs increased their concerns about HTP use, 22.6% were reassured about use, and 49.7% reported no effect. Factors associated with increased concern (vs. no effect) included other tobacco product use (aOR = 2.10, 95% CI 1.21-3.64) and being female (aOR = 1.77, 95% CI 1.03-3.05). Factors associated with being reassured about HTPs use (vs. no effect) included current HTP use (aOR = 2.11, 95% CI 1.11-4.00) and being from Israel (vs. US: aOR = 3.85, 95% CI 1.85-7.69), female (aOR = 1.91, 95% CI 1.07-3.42), and less educated (< college education: aOR = 2.57, 95% CI 1.42-4.63). Reporting that HWLs on HTPs increased concern (β = 0.46, 95% CI 0.03-0.89) and reassured of use (β = 0.94, 95% CI 0.47-1.41) were positively associated with HTP use intentions; no associations with risk perceptions were found.

CONCLUSIONS

Findings indicate that most tobacco users noticed HWLs on HTPs, but the majority reported no effect or being reassured of using HTPs, effects that were magnified for specific subgroups. Both increased concern and reassurance correlated with greater use intentions. Additional research should evaluate HTP HWL impacts and ensure effectiveness in communicating risks and discouraging use.

The impacts of electronic cigarette health warning labels on use intentions and perceptions: A cross-sectional study of US and Israeli adults who use tobacco

Background

Health warning labels (HWLs) are evidence-based tobacco control strategies; however, their application to e-cigarettes and related impacts (e.g. on perceived risk), including across countries with different regulations, are understudied.

Design and Methods

Using 2021 survey data from 927 US and Israeli adults reporting past-month tobacco use, multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of e-cigarette HWLs (i.e. more concerned about e-cigarette use, reassured, no effect) among those who noticed e-cigarette HWLs (multinomial regressions); and (2) HWL impacts in relation to use intentions and perceived addictiveness and harm (linear regressions).

Results

Among those who noticed HWLs (n = 835, 90.1%), 34.1% reported HWLs resulted in greater concern about e-cigarette use, 45.5% no effect, and 20.4% reassurance. Factors associated with greater concern (vs no effect) included e-cigarette non-use (vs use; aOR = 1.69, 95% CI:1.22, 2.38), US (vs Israel) resident (aOR = 1.65, 95% CI:1.16, 2.34), age 18-25 (vs 36-45; aOR = 1.72, 95% CI:1.11, 2.67), and more education (aOR = 1.85, 95% CI:1.30, 2.63). Factors associated with being reassured (vs no effect) included use of cigarettes (aOR = 1.71, 95% CI:1.06, 2.75), e-cigarettes (aOR = 2.64, 95% CI:1.77, 3.94), and other tobacco (aOR = 2.11, 95% CI:1.39, 3.21), and Israeli resident (aOR = 2.33, 95% CI:1.47, 3.70). Not noticing HWLs (vs no effect) correlated with lower intentions (β = -0.44, 95% CI:-0.87, -0.01), perceived addictiveness (β = -0.61, 95% CI:-1.05, -0.18), and harm (β = -0.56, 95% CI:-0.95, -0.18); reassurance correlated with greater use intentions (β = 0.48, 95% CI:0.12, 0.83); and greater concern was unassociated with use intentions or perceived risk.

Conclusion

Effects of differing e-cigarette HWLs in distinct subpopulations warrant research. Despite being noticed, they may have no effect or encourage e-cigarette use.

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.

Exploring the implications of modified risk claim placement in tobacco advertising

The United States Food and Drug Administration (FDA) has developed a regulatory process by which tobacco companies can apply to make "modified risk tobacco product" (MRTP) marketing claims that their product poses a lower risk of disease or exposure to harmful constituents. The impact of MRTP claims to promote harm reduction may be limited by perceptions that claims come from the tobacco industry, lack of attention, and the simultaneous presence of health warnings on ads, which may be perceived as conflicting information. Some studies have examined the potential of alternative "modified risk warnings". We aimed to contribute to this literature by exploring issues of claim attention, perceived source and credibility when viewing MRTP claims within or outside of a warning label. We conducted 11 focus groups with adult smokers and young adult (ages 18-25) non-smokers (n = 54) who viewed three e-cigarette or snus advertisements which varied in where an MRTP message was placed: outside the warning label, inside the warning label, or in a modified label style. Results suggest that MRTP claims presented within or in the style of a warning label (compared to claims outside the label), may be perceived as coming from a government or health-related source rather than a tobacco industry, and thus seem more credible. Yet these formats may receive insufficient message attention, as they are smaller and appear as part of labels consumers are accustomed to ignoring. Future research should further probe effects of MRTP statements and how they vary by message source, channel and format.

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.

Analysis of on-pack messages for e-liquids: a discrete choice study

BACKGROUND

Policymakers wishing to encourage smokers unable to quit to switch to using electronic nicotine delivery systems (ENDS) also need to consider how to deter ENDS use among non-smokers. We examined whether reduced-risk messages could increase ENDS' appeal among smokers and if increased-risk messages could decrease appeal among susceptible non-smokers, occasional and former smokers.

METHODOLOGY

An online discrete choice experiment tested three attributes: information message, nicotine content (0 mg or 3 mg) and flavour (tobacco, menthol or fruit). The sample comprised 352 current smokers, 118 occasional and former smokers, and 216 ENDS-susceptible never smokers. Smokers viewed reduced-risk messages that encouraged switching to ENDS, while other groups viewed increased-risk messages that discouraged ENDS use. All groups saw a typical addiction warning. We analysed the data by estimating multinomial logit regression and adjusted latent class analysis models.

RESULTS

Relative to no message, reduced risk-messages increased the appeal of ENDS uptake among one class of smokers (33.5%) but decreased appeal among other smokers. However, among all smokers, reduced-risk messages increased preference more than a dissuasive addiction warning. By contrast, among occasional or former smokers, and susceptible non-smokers, all information messages discouraging ENDS use, including an addiction warning, decreased preference relative to no message.

CONCLUSIONS

On-pack relative-risk messages about ENDS could make transition more attractive to smokers while increased-risk messages could deter ENDS uptake among susceptible non-smokers, occasional and former smokers. Communicating diverse messages via discrete channels could recognise heterogeneity among and between smokers and non-smokers.

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.

High School Youth and E-cigarettes: The Influence of Modified Risk Statements and Flavors on E-cigarette Packaging

Objectives: In this paper, we test variations of e-cigarette warning labels on high school youth, alone, and alongside modified risk statements (MRS) and/or flavors, to determine how perceptions of and intentions toward use of e-cigarettes are influenced by these package elements. Methods: An experiment (N = 715 high school youth) varied the warning label participants viewed (FDA warning label/ MarkTen warning label/ abstract warning label) and whether they viewed the label alone or alongside MRS and/or flavors. Results: Drawing upon the Heuristic Systematic Model, we found that youth who view an MRS with any of the warning labels are more likely to engage in counterarguing (compared to the FDA warning label alone), which increases risk perceptions. Additionally, the greater youth perceive the risks associated with e-cigarettes, the lower their intentions of using them, even if they have tried an e-cigarette in the past. Conclusions: Tobacco education and public health messages should encourage youth to evaluate the tobacco industry messages they receive, as counterarguing is associated with higher risk perceptions. Furthermore, fostering increased awareness of the risks associated with e-cigarette use by youth can reduce intentions to use them.

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.