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

The Normalization of Vaping on TikTok Using Computer Vision, Natural Language Processing, and Qualitative Thematic Analysis: Mixed Methods Study

BACKGROUND

Social media posts that portray vaping in positive social contexts shape people's perceptions and serve to normalize vaping. Despite restrictions on depicting or promoting controlled substances, vape-related content is easily accessible on TikTok. There is a need to understand strategies used in promoting vaping on TikTok, especially among susceptible youth audiences.

OBJECTIVE

This study seeks to comprehensively describe direct (ie, explicit promotional efforts) and indirect (ie, subtler strategies) themes promoting vaping on TikTok using a mixture of computational and qualitative thematic analyses of social media posts. In addition, we aim to describe how these themes might play a role in normalizing vaping behavior on TikTok for youth audiences, thereby informing public health communication and regulatory policies regarding vaping endorsements on TikTok.

METHODS

We collected 14,002 unique TikTok posts using 50 vape-related hashtags (eg, #vapetok and #boxmod). Using the k-means unsupervised machine learning algorithm, we identified clusters and then categorized posts qualitatively based on themes. Next, we organized all videos from the posts thematically and extracted the visual features of each theme using 3 machine learning-based model architectures: residual network (ResNet) with 50 layers (ResNet50), Visual Geometry Group model with 16 layers, and vision transformer. We chose the best-performing model, ResNet50, to thoroughly analyze the image clustering output. To assess clustering accuracy, we examined 4.01% (441/10,990) of the samples from each video cluster. Finally, we randomly selected 50 videos (5% of the total videos) from each theme, which were qualitatively coded and compared with the machine-derived classification for validation.

RESULTS

We successfully identified 5 major themes from the TikTok posts. Vape product marketing (1160/10,990, 8.28%) reflected direct marketing, while the other 4 themes reflected indirect marketing: TikTok influencer (3775/14,002, 26.96%), general vape (2741/14,002, 19.58%), vape brands (2042/14,002, 14.58%), and vaping cessation (1272/14,002, 9.08%). The ResNet50 model successfully classified clusters based on image features, achieving an average F1-score of 0.97, the highest among the 3 models. Qualitative content analyses indicated that vaping was depicted as a normal, routine part of daily life, with TikTok influencers subtly incorporating vaping into popular culture (eg, gaming, skateboarding, and tattooing) and social practices (eg, shopping sprees, driving, and grocery shopping).

CONCLUSIONS

The results from both computational and qualitative analyses of text and visual data reveal that vaping is normalized on TikTok. Our identified themes underscore how everyday conversations, promotional content, and the influence of popular figures collectively contribute to depicting vaping as a normal and accepted aspect of daily life on TikTok. Our study provides valuable insights for regulatory policies and public health initiatives aimed at tackling the normalization of vaping on social media platforms.

Codesign and Evaluation of Pain Science Messages on Social Media With Adolescents With a History of Chronic Pain

Pain science education (PSE) is an important component of pediatric pain care; however, access to services is limited. To disseminate pain science concepts on social media, we partnered with adolescents with chronic pain to codesign content. We engaged 7 adolescent codesigners (aged 13-18 years) with lived experience of chronic pain to take part in 4 codesign workshops. Codesigners actively contributed to the social media campaign by selecting the social media platform, dictating design principles, generating metaphors and language, and recommending changes to mock designs. Codesigners suggested expanding the intended audience of the campaign to include people without a lived experience of chronic pain, such as friends, family, and teachers, alongside targeting adolescents with chronic pain. We published 30 posts and 102 stories over an 18-week period on Instagram, which reached over 40,000 individuals. We evaluated codesigners' experience, where they reported having clear communication and necessary supports and information to participate; were able to share their ideas and felt they were heard; and felt their input was making a difference. The outputs of this campaign could be useful to guide the tailoring of other PSE content delivered by clinicians as part of clinical care. Future testing of the content generated in this codesign process could evaluate if it leads to meaningful changes in the lives of people with chronic pain. PERSPECTIVE: Researchers partnered with adolescents with chronic pain to codesign content for a social media campaign on PSE. Adolescent codesigners actively shaped the campaign direction, broadening its scope to reach diverse audiences. Our Instagram initiative reached over 40,000 individuals, indicating the potential for innovative educational approaches.

Exposure to user-generated e-cigarette content on social media associated with greater vulnerability to e-cigarette use among youth non-users

INTRODUCTION

Social media are important venues for youth's exposure to e-cigarette content. This study examined how exposure to user-generated e-cigarette content (i.e., content created and shared by individual social media users) is associated with vulnerabilities to e-cigarette use among youth non-users.

METHODS

We pooled data from the 2021 and 2022 National Youth Tobacco Survey. Youth who have never used e-cigarettes were included. Weighted linear and logistic regressions were conducted to examine how exposure to user-generated e-cigarette content (from real-life friends, online-only friends, and celebrities/influencers) on social media was associated with e-cigarette use vulnerabilities measured by perceived norms, perceived risk, and susceptibility of use, controlling for demographics, advertising exposure, and mental health conditions. Multiple imputations were performed to account for missing data.

RESULTS

Exposure to e-cigarette content on social media posted by real-life friends, online-only friends, and celebrities/influencers were associated with more positive descriptive norm (βs = 1.56, 0.37, and 0.35, respectively, all ps < .001), more positive injunctive norm (βs = 0.46, 0.19, and 0.10, respectively, all ps < .001), and higher odds of e-cigarette use susceptibility (ORs = 1.48, 1.50. 1.29, respectively, all ps < .001). Exposure to content posted by real-life and online-only friends were associated with reduced risk perception of e-cigarette use (β = -0.04, p < 0.05 and β = -0.07, p < 0.001).

CONCLUSIONS

Our study highlighted that friends and celebrities/influencers are important sources on social media that can influence youth non-users' vulnerabilities to e-cigarette use. Interventional messages communicated through friends and influencers on social media may in turn help reduce e-cigarette vulnerability among youth non-users.

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

INTRODUCTION

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

AIMS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Marketing Strategies Used by Tobacco Companies Targeting the Queer Community

Background: This study described the marketing strategies tobacco companies use to advertise tobacco products to the Queer community. Methods: In this secondary qualitative analysis, 15 Queer participants were interviewed to explore their life experiences with tobacco product advertisements during the early days of the COVID-19 pandemic. Results: Participants self-reported as male (n = 5), followed by female (n = 4), gender non-binary (n = 4) and, transgender (n = 2). In addition, most participants identified as Black/African American (n = 7) or White (n = 7). Many participants identified as Bisexual (n = 5) or Queer (n = 4). Using narrative analysis, the themes for this study were: (1) tobacco and vaping companies target minoritized and Queer people; (2) tobacco and vape companies maintain their presence by sponsoring local Lesbian, gay, bisexual, transgender, questioning, intersex, asexual, and other community (LGBTQIA+) bars and Pride events, often through giveaways and coupons; and (3) the use of social media influencers represents a new social marketing technique. As a result, Queer participants were more likely to encounter many different types of advertisements from tobacco companies and, most recently, social media influencers. Conclusion: Social media influencers are a new factor that needs further study to understand the new tobacco advertising landscape.

Young adults' visual attention to features of social media marketing for disposable e-cigarettes and associated perceptions

BACKGROUND AND AIMS

E-cigarette marketing exposure on social media influences perceptions; however, limited knowledge exists regarding marketing features attracting the most visual attention. This study examined visual attention to features of social media marketing for disposable e-cigarettes and related product perceptions.

DESIGN, SETTING AND PARTICIPANTS

Participants viewed 32 disposable marketing post images from social media (Instagram) using computer-based eye-tracking technology to assess standardized attention metrics of marketing features. They then completed a survey assessing positive product perceptions. The study took place in New Jersey, USA, June-September 2022, comprising young adults (aged 18-29) who do not use tobacco (n = 72) or who smoke cigarettes (n = 42).

MEASUREMENTS

We examined associations between 14 marketing features (e.g. product package, personal item, fruit/candy descriptor, social media account) and standardized attention metrics of dwell time (fixation duration) and entry time (time to first fixation). Then, we assessed attention metrics for each feature in relation to positive product perceptions (appeal and positive use expectancy).

FINDINGS

Among all participants, dwell time was the longest for the product descriptor [marginal means (MM) = 1.77; 95% confidence interval (CI) = 1.69, 1.86], social media account (MM = 1.76; 95% CI = 1.67, 1.85) and fruit/candy descriptor features (MM = 1.56; 95% CI = 1.41, 1.70); entry time was the shortest for the social media account (MM = 0.35; 95% CI = 0.26, 0.46), personal item (MM = 0.36; 95% CI = 0.17, 0.56) and human model features (MM = 0.40; 95% CI = 0.08, 0.72). Two use status groups had comparable dwell and entry times, except for the product descriptor feature. Longer dwell time for the product package feature increased positive product perceptions among both use status groups [regression coefficient (β) = 0.44 and 2.61]. Longer dwell time for fruit/candy descriptor (β = 1.80) and price promotion features (β = 4.04) increased positive product perceptions among those who smoke.

CONCLUSIONS

US young adults appear to be particularly visually engaged by disposable e-cigarette marketing that uses social media account features (account profile pictures, information about the products marketed and relevant hashtags) and features enhancing the products' personal relatability. Disposable product packages, fruit/candy descriptors and price promotions may increase the influence of social media marketing among various use status groups.

Association of time spent on social media with youth cigarette smoking and e-cigarette use in the UK: a national longitudinal study

BACKGROUND

Social media may influence children and young people's health behaviour, including cigarette and e-cigarette use.

METHODS

We analysed data from participants aged 10-25 years in the UK Household Longitudinal Study 2015-2021. The amount of social media use reported on a normal weekday was related to current cigarette smoking and e-cigarette use. Generalised estimating equation (GEE) logistic regression models investigated associations of social media use with cigarette smoking and e-cigarette use. Models controlled for possible confounders including age, sex, country of UK, ethnicity, household income and use of cigarette/e-cigarettes by others within the home.

RESULTS

Among 10 808 participants with 27 962 observations, current cigarette smoking was reported by 8.6% of participants for at least one time point, and current e-cigarette use by 2.5% of participants. In adjusted GEE models, more frequent use of social media was associated with greater odds of current cigarette smoking. This was particularly apparent at higher levels of use (eg, adjusted odds ratio (AOR) 3.60, 95% CI 2.61 to 4.96 for ≥7 hours/day vs none). Associations were similar for e-cigarettes (AOR 2.73, 95% CI 1.40 to 5.29 for ≥7 hours/day social media use vs none). There was evidence of dose-response in associations between time spent on social media and both cigarette and e-cigarette use (both p<0.001). Analyses stratified by sex and household income found similar associations for cigarettes; however, for e-cigarettes associations were concentrated among males and those from higher household income groups.

CONCLUSIONS

Social media use is associated with increased risk of cigarette smoking and e-cigarette use. There is a need for greater research on this issue as well as potential policy responses.

The Effect of Cigarette Content Marketing on Students' Smoking Behavior and Decisions: A PLS-SEM Approach

OBJECTIVE

This research aims to analyze the influence of cigarette content marketing on student behavior, and on cigarette purchasing decisions, as well as the influence of behavior on cigarette purchasing decisions.

METHODS

This research is quantitative, using a sample of 500 smoking students from twelve universities in the city of Medan, Indonesia, who were selected using a simple random sampling technique. Data collection was carried out by distributing questionnaires that had been tested for convergent validity with an Outer Loading value > 0.7 and an AVE value > 0.5, and for discriminant validity with an HTMT value < 0.9. The data was analyzed using a multivariate analysis technique which combines factor analysis and regression analysis.

RESULTS

The research results show that the t-statistical value for the behavioral variable (BHV) is 4.128 (> 1.98) and the p-value is 0.000 (< 0.05), which means that the BHV variable has a significant effect on the cigarette purchasing decision variable (PD). The t-statistical value for the content marketing (CM) variable is 27.57 (> 1.98) and the p-value is 0.000 (< 0.05), which means that the CM variable has a significant effect on the BHV variable. The t-statistical value for the CM variable is 18,542 (> 1.98) and the p-value is 0.000 (< 0.05), which means that the CM variable has a significant effect on the PD variable.  93.2% of respondents admitted that they had seen cigarette marketing content on social media, many of them (43%) believed that smoking was detrimental to their health, but the most influential factor was their perception regarding the activity of smoking.

CONCLUSION

Cigarette marketing content has been proven to influence students' behavior towards cigarettes, as well as directly influencing their decision to purchase cigarettes. Students' behavior towards cigarettes also influences their decisions in purchasing cigarettes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adolescents and Young Adults Use of Social Media and Following of e-Cigarette Influencers

BACKGROUND

With high rates of both e-cigarette and social media use among adolescents and young adults (AYAs), social media influencers who promote e-cigarettes are particularly concerning but are understudied. We examined the association between AYAs' use of 11 different social media platforms (e.g. Facebook, Twitter, Instagram, TikTok, and YouTube) and exposure to social media e-cigarette influencers.

OBJECTIVES

From November 2022 to February 2023, we conducted an online, US national survey of AYAs (14-29 years) who endorsed past-30-day e-cigarette use. We used binomial logistic regression to examine associations between the frequency of use of each social media platform and following e-cigarette influencers, controlling for age, sex, race, ethnicity, e-cigarette use frequency, and other tobacco and substance use (i.e., alcohol and cannabis). The model was stratified by adolescents (14-17 years; n = 293) and young adults (18-29 years; n = 654).

RESULTS

The most frequently used social media platforms were Snapchat, TikTok and Instagram among adolescents, and YouTube, Instagram and TikTok among young adults. In adjusted models, following e-cigarette influencers was associated with more frequent use of TikTok (adjusted odds ratio [95% CI]; 1.33 [1.05, 1.68]) and Pinterest (1.18 [1.02, 1.38]) among adolescents, and more frequent use of Twitter (1.17 [1.06, 1.29]) among young adults.

CONCLUSIONS

The use of different platforms was associated with exposure to e-cigarette influencers: TikTok and Pinterest among adolescents and Twitter among young adults. These findings can inform tobacco regulatory policy and social media platform restrictions of e-cigarette influencers on the platforms that are popular among AYAs.

Factors Associated With the Changes in Smoking and Electronic cigarette use in Adolescents During the COVID-19 Pandemic: A Longitudinal Analysis

PURPOSE

Explore the factors associated with the changes in smoking and electronic cigarette (e-cigarette) use and susceptibility among adolescents during the COVID-19 pandemic.

METHODS

We surveyed a cohort of students (7th-12th grade) from private schools in Guatemala. Baseline (May-September 2019) was conducted in-person and follow-up (June-November 2020) online during the lockdown. Separate Generalized Estimating Equations logistic models regressed current smoking (n = 3,729), current e-cigarette use (n = 3,729), smoking susceptibility among never-smokers (n = 2,596), and susceptibility to e-cigarette use among never-users (n = 1,597) on online ad exposure, visiting stores, social network smoking/e-cigarette use, substance use (alcohol, marihuana, and cigarette or e-cigarette), perceived harm of using cigarettes/e-cigarettes, sociodemographic characteristics, and survey wave. Interactions were assessed between time and ad exposures, friends smoking and e-cigarette use.

RESULTS

Frequency of store visits, exposure to online ads, and the use of cigarette and e-cigarette lowered at follow-up. Online e-cigarette ads, having family and friends who smoke, and current e-cigarette use increased the likelihood of being a current smoker. Frequent exposure to online e-cigarette ads, having family who use e-cigarettes, and being a current smoker were associated with higher likelihood of current e-cigarette use. Exposure to either online ads or having friends that smoke or use e-cigarettes, increased susceptibility to using either product. Interaction results showed that high exposure to online e-cigarette ads overtime increased the susceptibility to use e-cigarettes.

DISCUSSION

Exposure to online ads and friends and family cigarette and e-cigarette use increased adolescent consumption and susceptibility during the pandemic.

Identification and Characterization of Synthetic Nicotine Product Promotion and Sales on Instagram Using Natural Language Processing

INTRODUCTION

There has been a rapid proliferation of synthetic nicotine products in recent years, despite newly established regulatory authority and limited research into its health risks. Previous research has implicated social media platforms as an avenue for nicotine product unregulated sales. Yet, little is known about synthetic nicotine product content on social media. We utilized natural language processing to characterize the sales of synthetic nicotine products on Instagram.

METHODS

We collected Instagram posts by querying Instagram hashtags (eg, "#tobaccofreenicotine) related to synthetic nicotine. Using Bidirectional Encoder Representations from Transformers, collected posts were categorized into thematically related topic clusters. Posts within topic clusters relevant to study aims were then manually annotated for variables related to promotion and selling (eg, cost discussion, contact information for offline sales).

RESULTS

A total of 7425 unique posts were collected with 2219 posts identified as related to promotion and selling of synthetic nicotine products. Nicotine pouches (52.9%, n = 1174), electronic nicotine delivery systems (30.6%, n = 679), and flavored e-liquids (14.1%, n = 313) were most commonly promoted. About 16.1% (n = 345) of posts contained embedded hyperlinks and 5.8% (n = 129) provided contact information for purported offline transactions. Only 17.6% (n = 391) of posts contained synthetic nicotine-specific health warnings.

CONCLUSIONS

In the United States, synthetic nicotine products can only be legally marketed if they have received premarket authorization from the Food and Drug Administration (FDA). Despite these prohibitions, Instagram appears to be a hub for potentially unregulated sales of synthetic and "tobacco-free" products. Efforts are needed by platforms and regulators to enhance content moderation and prevent unregulated online sales of existing and emerging synthetic nicotine products.

IMPLICATIONS

There is limited clinical understanding of synthetic nicotine's unique health risks and how these novel products are changing over time due to regulatory oversight. Despite synthetic nicotine-specific regulatory measures, such as the requirement for premarket authorization and FDA warning letters issued to unauthorized sellers, access to and promotion of synthetic nicotine is widely occurring on Instagram, a platform with over 2 billion users and one that is popular among youth and young adults. Activities include direct-to-consumer sales from questionable sources, inadequate health warning disclosure, and exposure with limited age restrictions, all conditions necessary for the sale of various tobacco products. Notably, the number of these Instagram posts increased in response to the announcement of new FDA regulations. In response, more robust online monitoring, content moderation, and proactive enforcement are needed from platforms who should work collaboratively with regulators to identify, report, and remove content in clear violation of platform policies and federal laws. Regulatory implementation and enforcement should prioritize digital platforms as conduits for unregulated access to synthetic nicotine products and other future novel and emerging tobacco products.

Scalable Surveillance of E-Cigarette Products on Instagram and TikTok Using Computer Vision

INTRODUCTION

Instagram and TikTok, video-based social media platforms popular among adolescents, contain tobacco-related content despite the platforms' policies prohibiting substance-related posts. Prior research identified themes in e-cigarette-related social media posts using qualitative or text-based machine learning methods. We developed an image-based computer vision model to identify e-cigarette products in social media images and videos.

AIMS AND METHODS

We created a data set of 6999 Instagram images labeled for 8 object classes: mod or pod devices, e-juice containers, packaging boxes, nicotine warning labels, e-juice flavors, e-cigarette brand names, and smoke clouds. We trained a DyHead object detection model using a Swin-Large backbone, evaluated the model's performance on 20 Instagram and TikTok videos, and applied the model to 14 072 e-cigarette-related promotional TikTok videos (2019-2022; 10 276 485 frames).

RESULTS

The model achieved the following mean average precision scores on the image test set: e-juice container: 0.89; pod device: 0.67; mod device: 0.54; packaging box: 0.84; nicotine warning label: 0.86; e-cigarette brand name: 0.71; e-juice flavor name: 0.89; and smoke cloud: 0.46. The prevalence of pod devices in promotional TikTok videos increased by 15% from 2019 to 2022. The prevalence of e-juices increased by 33% from 2021 to 2022. The prevalence of e-juice flavor names and e-cigarette brand names increased by about 100% from 2019 to 2022.

CONCLUSIONS

Deep learning-based object detection technology enables automated analysis of visual posts on social media. Our computer vision model can detect the presence of e-cigarettes products in images and videos, providing valuable surveillance data for tobacco regulatory science (TRS).

IMPLICATIONS

Prior research identified themes in e-cigarette-related social media posts using qualitative or text-based machine learning methods. We developed an image-based computer vision model to identify e-cigarette products in social media images and videos. We trained a DyHead object detection model using a Swin-Large backbone, evaluated the model's performance on 20 Instagram and TikTok videos featuring at least two e-cigarette objects, and applied the model to 14 072 e-cigarette-related promotional TikTok videos (2019-2022; 10 276 485 frames). The deep learning model can be used for automated, scalable surveillance of image- and video-based e-cigarette-related promotional content on social media, providing valuable data for TRS. Social media platforms could use computer vision to identify tobacco-related imagery and remove it promptly, which could reduce adolescents' exposure to tobacco content online.

Tobacco promotion restriction policies on social media

Tobacco promotion is prolific on social media, with each platform setting their own restrictions on tobacco promotion and sales. We evaluated the policies related to tobacco product promotion and sales on 11 sites that are popular with youth in May 2021: Discord, Facebook, Instagram, Pinterest, Reddit, Snapchat, TikTok, Tumblr, Twitch, Twitter and YouTube. Nine of the 11 sites prohibited paid advertising for tobacco products. However, only three of them clearly prohibited sponsored content (ie, social influencers) that promotes tobacco. Six platforms restricted content that sells tobacco products and three tried to prohibit underage access to content that promotes or sells tobacco products. Although most platform policies prohibited paid tobacco advertising, few addressed more novel strategies, such as sponsored/influencer content and few had age-gating to prevent youth access. There is a pressing need to regulate tobacco promotion on social media platforms.

Social Network Analysis of e-Cigarette-Related Social Media Influencers on Twitter/X: Observational Study

BACKGROUND

An e-cigarette uses a battery to heat a liquid that generates an aerosol for consumers to inhale. e-Cigarette use (vaping) has been associated with respiratory disease, cardiovascular disease, and cognitive functions. Recently, vaping has become increasingly popular, especially among youth and young adults.

OBJECTIVE

The aim of this study was to understand the social networks of Twitter (now rebranded as X) influencers related to e-cigarettes through social network analysis.

METHODS

Through the Twitter streaming application programming interface, we identified 3,617,766 unique Twitter accounts posting e-cigarette-related tweets from May 3, 2021, to June 10, 2022. Among these, we identified 33 e-cigarette influencers. The followers of these influencers were grouped according to whether or not they post about e-cigarettes themselves; specifically, the former group was defined as having posted at least five e-cigarette-related tweets in the past year, whereas the latter group was defined as followers that had not posted any e-cigarette-related tweets in the past 3 years. We randomly sampled 100 user accounts among each group of e-cigarette influencer followers and created corresponding social networks for each e-cigarette influencer. We compared various network measures (eg, clustering coefficient) between the networks of the two follower groups.

RESULTS

Major topics from e-cigarette-related tweets posted by the 33 e-cigarette influencers included advocating against vaping policy (48.0%), vaping as a method to quit smoking (28.0%), and vaping product promotion (24.0%). The follower networks of these 33 influencers showed more connections for those who also post about e-cigarettes than for followers who do not post about e-cigarettes, with significantly higher clustering coefficients for the former group (0.398 vs 0.098; P=.005). Further, networks of followers who post about e-cigarettes exhibited substantially more incoming and outgoing connections than those of followers who do not post about e-cigarettes, with significantly higher in-degree (0.273 vs 0.084; P=.02), closeness (0.452 vs 0.137; P=.04), betweenness (0.036 vs 0.008; P=.001), and out-of-degree (0.097 vs 0.014; P=.02) centrality values. The followers who post about e-cigarettes also had a significantly (P<.001) higher number of followers (n=322) than that of followers who do not post about e-cigarettes (n=201). The number of tweets in the networks of followers who post about e-cigarettes was significantly higher than that in the networks of followers who do not post about e-cigarettes (93 vs 43; P<.001). Two major topics discussed in the networks of followers who post about e-cigarettes included promoting e-cigarette products or vaping activity (55.7%) and vaping being a help for smoking cessation and harm reduction (44.3%).

CONCLUSIONS

Followers of e-cigarette influencers who also post about e-cigarettes have more closely connected networks than those of followers who do not themselves post about e-cigarettes. These findings provide a potentially practical intervention approach for future antivaping campaigns.

E-Cigarette Brand Trends in the United States: An Investigation of Data From a Youth and Young Adult Sample and the E-Cigarette Retail Market (2022)

Background

Electronic cigarettes (e-cigarettes) remain the most used tobacco product among young people in the United States (US). Given the need for current data on popular e-cigarette products, the current study leverages data from a rapid surveillance survey of young people and examines whether the top e-cigarette brands identified from this source align with US market data.

Methodology

Data were obtained from current e-cigarette users (N = 4145) participating in the Truth Continuous Tracker Online (CTO; a cross-sectional tracking survey of 15-24 year-olds sourced from the national Dynata panel) and NielsenIQ retail scanner data, collected in 2022 and aggregated by quarter (Q1, Q2, and Q3). The top 15 e-cigarette brands were determined from respondents' endorsement in the Truth CTO and ranked total sales in NielsenIQ in nominal dollars.

Results

Overall, 58% of e-cigarette brands overlapped across the Truth CTO and NielsenIQ data (60% for Q1, 47% for Q2 and 67% for Q3). Pod-based (JUUL; VUSE) and disposable (Hyde; Breeze Smoke) brands appeared as top brands in both datasets. Top brands were fairly consistent within and across quarters; though, more variability was found in the Truth CTO, relative to NielsenIQ. Many top brands were disposable.

Conclusions

Results suggest that data from rapid surveillance and retail data can be used complementarily to characterize the popular e-cigarette brands currently on the US market. Many of these popular e-cigarette brands have yet to receive marketing granted orders under the US Food and Drug Administration, suggesting the need to continue monitoring e-cigarette brands among young people.

How to Identify e-Cigarette Brands Available in the United States During 2020-2022: Development and Usability Study

BACKGROUND

Prior studies have demonstrated that the e-cigarette market contains a large number of brands. Identifying these existing e-cigarette brands is a key element of market surveillance, which will further assist in policy making and compliance checks.

OBJECTIVE

To facilitate the surveillance of the diverse product landscape in the e-cigarette market, we constructed a semantic database of e-cigarette brands that have appeared in the US market as of 2020-2022.

METHODS

In order to build the brand database, we searched and compiled e-cigarette brands from a comprehensive list of retail channels and sources, including (1) e-liquid and disposable brands sold in web-based stores, (2) e-cigarette brands sold in brick-and-mortar stores and collected by the Nielsen Retail Scanner Data, (3) e-cigarette brands compiled by Wikipedia, (4) self-reported e-cigarette brands from the 2020 International Tobacco Control Four-Country Smoking and Vaping (ITC 4CV) US survey, and (5) e-cigarette brands on Twitter. We also estimated the top 5 e-cigarette brands by sales volume in brick-and-mortar stores, by the frequency and variety of offerings in web-based shops, and by the frequency of self-reported brands from the 2020 ITC 4CV US survey.

RESULTS

As of 2020-2022, a total of 912 e-cigarette brands have been sold by various retail channels. During 2020-2022, the top 5 brands are JUUL, vuse, njoy, blu, and logic in brick-and-mortar stores; blu, king, monster, twist, and air factory for e-liquids in web-based stores; hyde, pod mesh, suorin, vaporlax, and xtra for disposables sold in web-based stores; and smok, aspire, vaporesso, innokin, and eleaf based on self-reported survey data.

CONCLUSIONS

As the US Food and Drug Administration enforces the premarket tobacco market authorization, many e-cigarette brands may become illegal in the US market. In this context, how e-cigarette brands evolve and consolidate in different retail channels will be critical for understanding the regulatory impacts on product availability. Our semantic database of e-cigarette brands can serve as a useful tool to monitor product and marketplace development, conduct compliance checks, assess manufacturers' marketing behaviors, and identify regulatory impacts.

Characterizing Anti-Vaping Posts for Effective Communication on Instagram Using Multimodal Deep Learning

INTRODUCTION

Instagram is a popular social networking platform for sharing photos with a large proportion of youth and young adult users. We aim to identify key features in anti-vaping Instagram image posts associated with high social media user engagement by artificial intelligence.

AIMS AND METHODS

We collected 8972 anti-vaping Instagram image posts and hand-coded 2200 Instagram images to identify nine image features such as warning signs and person-shown vaping. We utilized a deep-learning model, the OpenAI: contrastive language-image pre-training with ViT-B/32 as the backbone and a 5-fold cross-validation model evaluation, to extract similar features from the Instagram image and further trained logistic regression models for multilabel classification. Latent Dirichlet Allocation model and Valence Aware Dictionary and sEntiment Reasoner were used to extract the topics and sentiment from the captions. Negative binomial regression models were applied to identify features associated with the likes and comments count of posts.

RESULTS

Several features identified in anti-vaping Instagram image posts were significantly associated with high social media user engagement (likes or comments), such as educational warnings and warning signs. Instagram posts with captions about health risks associated with vaping received significantly more likes or comments than those about help quitting smoking or vaping. Compared to the model based on 2200 hand-coded Instagram image posts, more significant features have been identified from 8972 AI-labeled Instagram image posts.

CONCLUSION

Features identified from anti-vaping Instagram image posts will provide a potentially effective way to communicate with the public about the health effects of e-cigarette use.

IMPLICATIONS

Considering the increasing popularity of social media and the current vaping epidemic, especially among youth and young adults, it becomes necessary to understand e-cigarette-related content on social media. Although pro-vaping messages dominate social media, anti-vaping messages are limited and often have low user engagement. Using advanced deep-learning and statistical models, we identified several features in anti-vaping Instagram image posts significantly associated with high user engagement. Our findings provide a potential approach to effectively communicate with the public about the health risks of vaping to protect public health.

Young people's views about the use of celebrities and social media influencers in gambling marketing

Young people's exposure to gambling marketing has had a clear impact on their gambling attitudes, risk perceptions and consumption intentions. Celebrities and social media influencers (SMIs) are increasingly used by the gambling industry in a wide range of promotions. While there is evidence that these types of promotions are influential in shaping young people's attitudes towards other harmful products, there is limited evidence in relation to gambling. Qualitative focus groups (n = 22) with n = 64, 12-17 year olds were conducted in Australia. These investigated young people's exposure to celebrity and SMI marketing for gambling and the influence they perceived this marketing had on young people's gambling attitudes. Reflexive thematic analysis was used to construct four themes from the data. First, young people perceived that celebrities and SMIs created additional appeal and recall of gambling advertisements because they were attention grabbing and familiar. Second, young people thought that celebrities and SMIs increased the trust, legitimacy and social acceptance of gambling. Third, the use of celebrities and SMIs lowered the perceptions of risk associated with gambling. Lastly, there were suggestions to reduce the impact of celebrity and SMI gambling promotions on young people, such as bans and restrictions. This study highlights the importance of a comprehensive approach to preventing young people's exposure to gambling marketing, that not only considers imposing stronger regulations to restrict the way the gambling industry is allowed to promote its products, but also aims to counter the novel ways the gambling industry attempts to appeal to children and young people.

Cross-sectional study of the associations between the implementation of the WHO FCTC tobacco advertising, promotion and sponsorship bans and current e-cigarette use among youth from countries with different income levels

BACKGROUND

The WHO Framework Convention on Tobacco Control (WHO FCTC) Article 13 requires countries to ban tobacco advertising, promotion and sponsorship (TAPS), and bans are recommended to cover electronic cigarettes (e-cigarettes). We examined youth e-cigarette prevalence by TAPS regulations in countries with different income levels.

METHODS

We analysed data on 165 299 respondents from 48 countries with 2016/2018 WHO FCTC implementation reports and 2016-2019 Global Youth Tobacco Survey. We used multilevel logistic regressions to examine associations between TAPS regulations and current e-cigarette use, stratified by country income.

RESULTS

About 1 in 10 respondents was currently using e-cigarettes. Respondents in countries with TAPS bans on the internet were less likely to use e-cigarettes (adjOR=0.58; 95% CI 0.39 to 0.86) than youth in countries without such bans. In lower middle-income and low-income countries, bans on displaying tobacco products at the point of sale (adjOR=0.55; 95% CI 0.34 to 0.90), bans on product placement (adjOR=0.44; 95% CI 0.28 to 0.69) and strength of additional TAPS measures were associated with lower prevalence of e-cigarette use among students. Being taught about the dangers of the use of tobacco in school was associated with lower odds of e-cigarette use. No differences in the use of e-cigarettes were observed by types of TAPS among respondents in high-income countries.

CONCLUSIONS

Strengthening implementation of TAPS policies and assuring they cover new and emerging products, online channels and points of sales are essential, especially in lower income countries. Maintaining tobacco health education is also important to protect youth from e-cigarette use.

Exposure to E-Cigarette Advertisements or Reviews and E-Cigarette Use Progression: A Longitudinal Examination of Short-Term and Long-Term Associations among US Young Adults

Limited research has investigated the impact of e-cigarette advertising and reviews on the progression of e-cigarette use among young adults in the US. This study utilized five-wave longitudinal data (2018-2020) with 3006 young adults aged 18-34, reporting exposure to e-cigarette advertisements or reviews at Wave 1 (W1) and W3. Generalized estimating equations (GEE) were used to examine the prospective associations between frequent exposure to e-cigarette advertisements or reviews and e-cigarette use progression in four groups: never users (n = 1271 at W1), former users (previously used but quit ≥ 6 months ago, n = 422 at W1), recent former users (used in the past 6 months but not in the past month, n = 186 at W1), and current users (used in the past month, n = 1127 at W1). Among baseline former users, frequent exposure to e-cigarette reviews was associated with current use at 6-month follow-up (aOR = 4.40, 95%CI = 1.46-13.29). Among baseline current users, frequent exposure to e-cigarette reviews was associated with increased days of use at 6-month follow-up (IRR = 1.20, 95%CI = 1.07-1.34) and 12-month follow-up (IRR = 1.18, 95%CI = 1.03-1.35). E-cigarette reviews may contribute to relapse among recent former users and increased usage frequency among current users, highlighting the need for enhanced e-cigarette promotional activity regulation.

E-cigarettes on Instagram: Exploring vape content via an Australian vaping influencer

INTRODUCTION

Mounting evidence suggests that electronic cigarettes (e-cigarettes) are extensively promoted and marketed using social media, including through user-generated content and social media influencers. This study explores how e-cigarettes are being promoted on Instagram, using a case-study approach, and the extent to which Meta's Restricted Goods and Services Policy (Meta's policy) is being applied and enforced.

METHODS

We identified the accounts followed by an Australian Instagram influencer who primarily posts e-cigarette-related content. The main foci of these 855 accounts were coded and 369 vaping-focused accounts were identified. These vaping-focused accounts were then further coded by two trained coders.

RESULTS

All (n=369; 100.0%) of the vape content posted by these accounts was positive in sentiment. One-third of the vape accounts (n=127; 34.4%) had a shared focus, indicating that vape content may permeate into other online communities through shared interests. A total of 64 accounts (17.3%) potentially violated Meta's policy by attempting to purchase, sell, raffle or gift e-cigarette products.

CONCLUSIONS

The findings of this study suggest that pro-vaping information is available and accessible on Instagram. Much of the content identified in this study promoted the purchase or gifting of e-cigarette products and potentially violates Meta's policy. Greater regulation and/or stronger enforcement of e-cigarette content on social media platforms such as Instagram is necessary to prevent the ongoing promotion of these harmful products.

Awareness of electronic cigarette industry practices and their associations with anti-electronic cigarette attitudes among susceptible US young adults

BACKGROUND

Public education exposing cigarette industry practices have been effective in changing attitudes and preventing smoking among young people. It is unclear how much young adults are aware of e-cigarette industry practices, and how this awareness relates to anti-e-cigarette attitudes. We examined demographic correlates of awareness of e-cigarette industry practices and anti-e-cigarette attitudes, and the association between awareness of these practices with anti-e-cigarette attitudes.

METHODS

A US sample of young adults aged 18-30 years who do not use commercial tobacco products but are susceptible to e-cigarette use were cross-sectionally surveyed through online panel services from August 2021 to January 2022. Respondents reported their demographics, awareness of cigarette industry practices, awareness of e-cigarette industry practices and their level of agreement with four anti-e-cigarette attitude statements. We used multivariable linear regressions to examine demographic associations and the relationship between awareness of e-cigarette industry practices with each anti-e-cigarette attitude, adjusting for demographics and awareness of cigarette industry practices.

RESULTS

Generally, Hispanic and Black young adults (vs White) and those with

DISCUSSION

Public education exposing e-cigarette industry practices may promote anti-e-cigarette attitudes among susceptible young adults who do not use commercial tobacco products. Future research should investigate the utility of anti-e-cigarette industry messaging.

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Key Words

• Denormalization
• Electronic nicotine delivery devices
• Prevention

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MESH Headings Collapse

Grants

• R00 CA272919 NCI NIH HHS
• U54 CA267735 NCI NIH HHS
• ZIA MD000006 Intramural NIH HHS

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Affiliation(s)

Lilianna Phan Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA Department of Community Health and Prevention, Dornsife School of Public Health and Division of Graduate Nursing, College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania, USA
Kelvin Choi Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA

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Exposure to e-cigarette advertisements and non-advertising content in relation to use behaviors and perceptions among US and Israeli adults

INTRODUCTION

As e-cigarette marketing strategies diversify, it is important to examine exposure to and impact of e-cigarette advertisements and non-advertising content (e.g. on social media) via multiple media channels among adults in different regulatory contexts.

METHODS

Using 2021 cross-sectional data among 2222 adults in the US (n=1128) and Israel (n=1094), multivariable regression examined past-month e-cigarette advertisement and non-advertising content exposure in relation to past-month e-cigarette use (logistic regression), as well as use intentions and risk perceptions (linear regressions), controlling for sociodemographics and tobacco use.

RESULTS

Overall, 20.3% reported past-month e-cigarette use (15.5% US, 25.2% Israel), 46.1% any advertisement exposure (28.7% digital media, 25.2% traditional media, 16.8% retail settings), and 34.1% any non-advertising exposure (19.4% social media, 13.6% websites, 12.3% movie/television/theater, 5.8% radio/podcasts). Exposure to digital media advertisements (AOR=1.95; 95% CI: 1.42-2.66), traditional media advertisements (AOR=2.00; 95% CI=1.49-2.68), and social media non-advertising (AOR=1.72; 95% CI: 1.25-2.36) correlated with e-cigarette use. Exposure to traditional media advertisements (β=0.23; 95% CI: 0.08-0.38) and social media non-advertising (β=0.26; 95% CI: 0.09-0.43) correlated with use intentions. Exposure to digital media advertisements (β= -0.32; 95% CI: -0.57 - -0.08), retail setting advertisements (β= -0.30; 95% CI: -0.58 - -0.03), and radio/podcast non-advertising (β= -0.44; 95% CI: -0.84 - -0.03) correlated with lower perceived addictiveness. Radio/podcast non-advertising exposure (β= -0.50; 95% CI: -0.84 - -0.16) correlated with lower perceived harm. However, retail setting advertisement exposure was associated with e-cigarette non-use (AOR=0.61; 95% CI: 0.42-0.87), and traditional media advertisement (β=0.38; 95% CI: 0.15-0.61) and social media non-advertising exposure (β=0.40; 95% CI: 0.14-0.66) correlated with greater perceived addictiveness.

CONCLUSIONS

E-cigarette-related promotional content exposure across media platforms impacts perceptions and use, thus warranting regulation.

Influence of Disclosed and Undisclosed Funding Sources in Tobacco Harm Reduction Discourse: A Social Network Analysis

INTRODUCTION

Tobacco harm reduction (THR) discourse has been divisive for the tobacco control community, partially because it sometimes aligns public health and tobacco industry interests. Industry funding is contentious as it influences study outcomes, and is not always disclosed in scientific publications. This study examines the role of disclosed and undisclosed industry support on THR publications via social network analysis.

METHODS

We reviewed 826 English-language manuscripts (1992-2016) to determine disclosed and undisclosed industry (pharmaceutical, tobacco, and e-cigarette) and non-industry (including government) support received by 1405 authors. We used social network analysis to identify the most influential authors in THR discourse by assessing the number of their collaborators on publications, the frequency of connecting other authors in the network, and tendency to form groups based on the presence of sponsorship disclosures, sources of funding, and THR stance.

RESULTS

About 284 (20%) out of 1405 authors were supported by industry. Industry-sponsored authors were more central and influential in the network: with twice as many publications (Median = 4), 1.25 as many collaborators on publications (Median = 5), and higher likelihood of connecting other authors and thus having more influence in the network, compared to non-industry-sponsored authors. E-cigarette industry-sponsored authors had the strongest association with undisclosed industry support.

CONCLUSIONS

Authors with industry support exerted a stronger influence on the THR scientific discourse than non-industry-supported authors. Journals should continue adhering to strict policies requiring conflicts of interest disclosures. An increase in public health spending on tobacco control research may be necessary to achieve funding parity.

Trends in E-Cigarette and Tobacco Cigarette Purchasing Behaviors by Youth in the United States, Canada, and England, 2017-2022

Objectives: This paper describes trends in youth e-cigarette (EC) and tobacco cigarette (TC) purchasing behaviors in Canada, England, and the United States (US) in relationship to changing minimum legal age (MLA) laws. Methods: Data are from eight cross-sectional online surveys among national samples of 16- to 19-year-olds in Canada, England, and the US conducted from 2017 to 2022 (N = 104,467). Average wave percentage change in EC and TC purchasing prevalence and purchase locations were estimated using Joinpoint regressions. Results: EC purchasing increased between 2017 and 2022, although the pattern of change differed by country. EC purchasing plateaued in 2019 for the US and in 2020 for Canada, while increasing through 2022 for England. TC purchasing declined sharply in the US, with purchasing from traditional retail locations declining, while purchasing from social sources increased. Vape shops were the most common location for EC purchasing, although declining in England and the US. Conclusion: Trends in EC and TC purchasing trends in the US are consistent with the expected impact of the federal MLA law increasing the legal age to 21 years in December 2019.

Longitudinal relationship between social media and e-cigarette use among adolescents: the roles of internalizing problems and academic performance

BACKGROUND

Prior research has investigated the influence of social media on e-cigarette use among adolescents, predominantly through the display of e-cigarette content and advertisements. However, the psychological mechanism underlying this relationship remains underexplored. This study aims to address the mediating effect of youths internalizing problems and elucidate the moderating effect of academic performance from a longitudinal perspective.

METHODS

Panel data from the Public Assessment of Tobacco and Health (PATH) Study Waves 3-5 (2015-2019) were utilized in this study. The sample consisted of 3,975 youths between the ages of 12 and 17 years old. A moderated mediation model was utilized for analyses.

RESULTS

Adolescents using social media more frequently in Wave 3 reported higher odds of internalizing problems in Wave 4 (bp = 0.061, p < .01), which led to more e-cigarette use in Wave 5 (bp = 0.029, p < .01). A negative moderating effect of academic performance was found in the association between internalizing problems and e-cigarette use (bp=-0.088, p < .05).

CONCLUSIONS

Frequent social media use among young individuals leads to an increase in e-cigarette use through enhanced internalizing problems. However, adolescents who perform well academically exhibit higher resistance to e-cigarette use. Based on our findings, we recommend that tailored anti-e-cigarette campaigns and mental health interventions be used to target frequent social media users and academically struggling adolescents to prevent adverse health outcomes.

Youth's exposure to and engagement with e-cigarette marketing on social media: a UK focus group study

OBJECTIVE

Electronic-cigarettes (e-cigarette) are promoted creatively through social media and considering the potential influence of social media marketing on young people, we explored young people's exposure to and engagement with social media marketing of e-cigarettes.

DESIGN

Semistructured discussion groups.

SUBJECTS

Twenty focus groups with 82 young people aged 11-16 living in the Central belt of Scotland.

METHODS

Youths were asked about smoking and vaping behaviours, social media use, vaping advertisement exposure and were shown illustrative examples of social media content (eg, images and videos) about different messages, presentations and contextual features. Transcripts were imported into NVivo V.12, coded thematically and analysed.

RESULTS

Youths highlighted a variety of tactics e-cigarette companies use, including influencer or celebrity endorsement, attractive youth flavours, bright colours and emotional appeal to advertise and promote their products directly to young people. Social media influencers who advertise e-cigarettes were described as portraying e-cigarettes as 'cool' and 'fashionable' to entice viewers to try the products. Youths considered that there is a need for more restrictions on social media content to protect youths while also still allowing smokers to purchase them as a cessation device.

CONCLUSIONS

Our study highlights that the e-cigarette industry is using previously employed tactics similar to the tobacco industry to advertise and promote its products on social media. These findings suggest the growing need for governments to work together to develop and implement policies to restrict the advertising and marketing of e-cigarettes on social media.

Community and Opinion Leadership Effects on Vaping Discourse: A Network Analysis of Online Reddit Threads

Reddit is a popular hub for discussing vaping. A deeper understanding of the factors that influence this online discourse could inform public health messaging efforts targeting this platform. Using a network analysis framework, we sought to investigate the role of opinion leaders and online communities in facilitating vaping discussions on Reddit. We collected Reddit submissions about vaping posted in May 2021 and used these submissions to generate subreddit-level (N=261) and thread-level (N=8,377) data sets. We coded subreddits into four community categories: 1) Vaping, 2) Substance use, 3) Cessation, and 4) Non-specific. We used sociometric in-degree centrality statistics to identify subreddit opinion leaders. We computed non-parametric ANOVAs and negative binomial regressions to test associations between opinion leadership and subreddit community category variables on subreddit network composition (comprised of subreddit-level network nodes and edges) and the number of commenters on Reddit threads about vaping (thread-level). Subreddit network composition was largely dependent on opinion leaders in Non-specific communities, and less so in Vaping and Substance use communities. At the thread-level, the rate of commenters was higher among threads initiated by opinion leaders than non-opinion leaders (adjusted rate ratio [aRR]=4.84). Furthermore, threads posted in Vaping (aRR=1.64), Substance use (aRR=1.92), and Cessation (aRR=1.21) communities had higher commenter rates than those posted in Non-specific communities. Communities and opinion leaders play a key role in the composition and reach of vaping discussions on Reddit. These findings provide a foundation for public health campaigns and interventions targeting Reddit and perhaps other social media platforms.

Social media use and cannabis vaping initiation among US youth

BACKGROUND

Youth cannabis vaping has increased in recent years, and there is growing evidence of cannabis vaping content on social media. This study investigated if social media use is associated with the initiation of cannabis vaping among US youth, using the youth dataset from Population Assessment of Tobacco and Health (PATH) Study Waves 4 (2016-2018) and 5 (2018-2019).

METHODS

Using youth respondents who never vaped cannabis at Wave 4 (N=8357), we conducted a multivariable logistic regression analysis on initiation of cannabis vaping at Wave 5 (i.e., ever-vaped cannabis) by frequency of social media use, after controlling for covariates (e.g., sociodemographic, other tobacco and substance use).

RESULTS

In this analytic sample, 66.5% reported daily social media use, 16.2% reported non-daily and 17.3% reported 'not having a social media account' or 'no social media use' at Wave 4. Further, 14.0% (n=1183) initiated cannabis vaping at Wave 5. In the multivariable logistic regression model, daily social media use (vs. never use; aOR=2.68; 95% CI=2.05, 3.49) and non-daily social media use (vs. never use; aOR=1.54; 95% CI=1.14, 2.09) at Wave 4 were associated with cannabis vaping initiation at Wave 5.

CONCLUSIONS

Our evidence suggests that social media use by youth is associated with cannabis vaping initiation among youth in subsequent years, even after controlling for other risk factors. Consistent surveillance and regulation of cannabis vaping-related content on social media, as well as prevention efforts, including counter-messaging on social media about the potential harms of cannabis vaping, are critically needed.

Exposure to E-Cigarette Advertising and Its Association With E-Cigarette Use Among Youth and Adolescents in Two Largest Cities in Vietnam 2020

BACKGROUND

E-cigarette products have become more popular due to the marketing campaigns on various sources but caused adverse health impacts to users, especially adolescents and youths. This paper aims to describe the situation of exposure to e-cigarette advertisements of youth and adolescents living in two cities of Hanoi and Ho Chi Minh in 2020 and identify the associated factors of e-cigarette marketing with e-cigarettes use in these groups.

METHODOLOGY

This was a cross-sectional study. The study participants were 1211 youth and adolescents aged 15-24 living in Hanoi and Ho Chi Minh City during the time of data collection (from January 2020 to September 2020). Two primary outcome variables included the ever e-cigarettes use and the intention to use e-cigarettes. Multivariate logistic regression models were used to assess the association between the outcome variables and e-cigarette marketing exposure.

RESULTS

The proportion of participants who ever use e-cigarettes was 7.4% and a proportion of 4.8% have intention to use e-cigarettes. The most popular source of exposure to e-cigarettes advertisements was social network (Facebook, Twitter, Instagram, Youtube, etc.) and this source had positive association with the odds of e-cigarette smoking among youth and adolescents (OR = 3.38, 95% CI: 1.59-7.14). In addition, referral marketers also contributed to making the participants more likely to smoke e-cigarettes (OR = 2.68, 95% CI: 1.03-6.95). Attractive color and free sample of e-cigarettes were also found to be the motivated factors associated with smoking behaviour among youth and adolescents.

CONCLUSIONS

New policies should be considered to oppose the impact of youth-oriented e-cigarette advertisements which include regulating and restricting e-cigarette advertisements on social media, as well as through referral marketers.

Exclusive and dual use of electronic cigarettes among European youth in 32 countries with different regulatory landscapes

BACKGROUND

The Tobacco Products Directive (2014/40/EU) partially harmonised the regulation of electronic cigarettes (e-cigarettes) in Europe, but individual countries maintain jurisdiction over bans on use in public places, domestic advertising, taxation and flavour regulations. Their association with youth e-cigarette use has not been examined.

METHODS

We used the cross-sectional 2019 European School Survey Project on Alcohol and Other Drugs data from 32 countries with 98 758 students aged 15-16 years and the 2020 WHO's assessment of the e-cigarette regulations. Multilevel logistic regression models on ever (vs never) and current (vs non-current) exclusive e-cigarette use, exclusive cigarette use and dual use by e-cigarette regulations' composite score were adjusted for age, gender, parental education, perceived family's financial well-being, perceived difficulty of obtaining cigarettes, country income level and general progress in tobacco control.

RESULTS

Of the respondents, 13.3% had ever used cigarettes, 10.6% e-cigarettes and 27.3% both; 13.0% currently used cigarettes, 6.0% e-cigarettes and 6.4% both. Higher composite country score in the e-cigarette regulations was associated with lower current exclusive e-cigarette use (OR=0.78; 95% CI 0.65 to 0.94) and current dual use (OR=0.80; 95% CI 0.67 to 0.95). Youth perceiving more difficulties in obtaining cigarettes were less likely to use cigarettes, e-cigarettes and both ever and currently (OR from 0.80 (95% CI 0.76 to 0.85) to 0.94 (95% CI 0.92 to 0.96)).

CONCLUSIONS

More comprehensive e-cigarette regulations and enforcement of age-of-sale laws may be protective of e-cigarette and dual use among adolescents.

Tobacco advertising exposure and product use among young adults: An ecological momentary assessment approach

INTRODUCTION

Tobacco-related content is prevalent on social media, yet many methods of measuring exposure are inadequate due to the personalized nature of online marketing. The purpose of this paper is to examine the association between exposure to pro-tobacco messages (both industry-sponsored and user-generated) and the use of tobacco products, as reported via ecological momentary assessment (EMA).

METHODS

Young adults (n = 175) were instructed to record all sightings of marketing (both in-person and online) related to tobacco for 28 days. Tobacco product use and recall of message encounters were assessed daily using app-initiated EMA.

RESULTS

Participants who reported exposure to tobacco messages were significantly more likely to report using tobacco, adjusting for gender, age, race/ethnicity, baseline use of any tobacco product, and having friends who use tobacco and e-cigarettes (p <.001). For each industry-sponsored message viewed, the odds of using tobacco or e-cigarettes in a given day increased by a factor of 1.77 (95 % CI = 1.41, 2.23). For each user-generated message viewed, the odds of using tobacco or e-cigarettes in a given day increased by a factor of 1.52 (95 % CI = 1.27, 1.83).

DISCUSSION

To our knowledge, this is the first study to specifically examine the association between exposure to user-generated messages and daily tobacco use. The findings suggests that there is a unique element to user-generated messages that distinguishes them from both traditional marketing and from simple peer influence.

E-Cigarette Retailers' Use of Instagram in New Zealand: A Content Analysis

E-cigarette companies claim their products are key to improving health outcomes by providing smokers with lower-risk alternatives. However, the rapid uptake of e-cigarettes among young people has prompted concern about company marketing practices. In 2019, there was no legislation to govern e-cigarette marketing in New Zealand. This period provides an ideal context for examining how e-cigarette companies promoted their products before the introduction of marketing regulations. We conducted a content analysis of the Instagram accounts of five prominent e-cigarette retailers based in New Zealand during 2019-2020. We assessed health- and risk-related claims and marketing techniques. Less than 10% of Instagram posts refer to smoking alternatives or risk of nicotine addiction. E-cigarette devices were more likely to be promoted for stylistic features such as colours and ease of use (29.7%). Music festival sponsorship (19.1%), social media influencers (9.2%), and lifestyle marketing (41.5%) were identified as youth-oriented promotional strategies. E-cigarette retailers claim to promote harm-reduction tools to smokers, yet this study finds few references to smoking alternatives in any content. Instead, retailers utilised strategies to engage with a young audience, including festival sponsorship and stylish influencers. This youth-oriented marketing, in combination with weak and delayed government action, may have contributed to the high use of e-cigarettes among young New Zealanders.

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

Background

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

Methodology

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

Results

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

Discussion

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

A content analysis of e-cigarette marketing on social media: Findings from the Tobacco Enforcement and Reporting Movement (TERM) in India, Indonesia and Mexico

Background

The use of e-cigarettes is proliferating globally, especially among youth and even children. Marketing is a known risk factor for e-cigarette initiation, yet little is known of e-cigarette marketing on social media in low- and middle-income countries. This study compares e-cigarette social media marketing in India, Indonesia, and Mexico, three such countries with different regulatory environments.

Methods

Instances of e-cigarette marketing on social media platforms were identified via the Tobacco Enforcement and Reporting Movement (TERM), a digital tobacco marketing monitoring system. Through systematic keyword-based searches, all tobacco marketing posts observed between 15 December 2021 and 16 March 2022 were included in the analysis. The final sample included 1,437 e-cigarette-related posts on Instagram, Facebook, Twitter, YouTube, and TikTok, which were systematically content analyzed by independent coders after inter-reliability (Cohen's Kappa K > 0.79) was established using a theory-derived codebook. The final data is represented in percentages and frequencies for ease of presentation.

Results

We observed e-cigarette marketing online in all countries studied, yet there was variation in the volume of marketing and types of accounts identified. In India, where e-cigarettes were comprehensively banned, we identified 90 (6%) posts; in Mexico, where e-cigarettes were partially restricted, 318 (22%) posts were observed; and in Indonesia, where there were no restrictions, 1,029 (72%) posts were observed. In both India and Mexico, marketing originated from retailer accounts (100%), whereas in Indonesia, it was primarily product brand accounts (86%). Across countries, e-cigarettes were mostly marketed directly to sell products (India: 99%, Indonesia: 69% and Mexico: 93%), though the sales channels varied. Product features, including e-liquid flavors, device colors and technical specifications, was the most prominent message framing (India: 86%; Mexico: 73%; Indonesia: 58%). Harm reduction messaging was most popular in Mexico (8%) and was not common in Indonesia (0.3%) or India (0%).

Conclusion

Our study provides important insights for tobacco control stakeholders on the evolving nature of e-cigarette marketing in low- and middle-income countries. It underscores the presence of e-cigarette marketing, including in countries where comprehensive regulations exist, and suggests the importance of continuous monitoring to keep up with industry practices and strengthen tobacco control stakeholder efforts to counter them.

Industry response to strengthened regulations: amount and themes of flavoured electronic cigarette promotion by product vendors and manufacturers on Instagram

Background

Social media discussion tends to follow news about proposed or enacted government policies. Thus, digital discourse surveillance may be an effective and unobtrusive way of understanding industry and public response to policies and regulations, including in the domain of tobacco control. Recently, the US Food and Drug Administration restricted sales of flavoured cartridge and disposable vape products. Historically, the tobacco industry used modification of product characteristics, labelling or packaging to work around flavour restrictions. We aimed to characterise strategies used by nicotine product manufacturers and vendors to promote flavoured products on Instagram and to identify policy workaround tactics.

Methods

Keyword rules were used to collect flavoured electronic cigarette-related Instagram posts from CrowdTangle, from 1 January 2019 to 31 December 2021. Posts were coded for commercial content and promotional strategies using a combination of machine learning methods, keyword algorithms and human coding. Additional exploratory analyses were conducted to identify major discussion themes. Non-English posts were excluded from the analyses.

Results

Keyword filters captured 113 393 relevant posts from 391 unique accounts, with 46 076 posts referencing flavour promotion (40.6%) and 2124 (2%) posts mentioning alternatives to restricted flavoured products or strategies to evade flavour sales restrictions. Promotional messages featured non-characterising flavour references, ‘off-brand’ product substitutes, promotion of new flavoured product technologies, innovation, do-it-yourself appeals, global promotion, international delivery and encouraged flavoured product stockpiling. In addition, promotion of refillable devices, e-juice, tank systems and ‘box mod’ vaporizers was present.

Conclusion

Social media surveillance can enhance our understanding of public health needs and policy compliance, as well as inform strategies to prevent policy evasion. Examining evolving industry tactics to promote flavoured products in response to regulatory changes can help authorities and practitioners assess policy effectiveness and inform future design and implementation approaches.

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

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

Use of e-cigarettes among public health students in Thailand: Embedded mixed-methods design

INTRODUCTION

E-cigarettes are new tobacco products widely used among adolescents. Public health students are not only susceptible to e-cigarette use, but they should also serve as non-smoking role models. The study aimed to investigate the current situation of e-cigarette use and the factors associated with its use among public health students.

METHODS

In this embedded mixed-methods design, the primary approach was a cross-sectional online survey. The samples were 2302 third-year public health students from 37 public health education institutes across Thailand. Stratified two-stage cluster random sampling was employed to select the subjects. Data were collected using self-administered questionnaires from January to March 2021. A checklist form was employed to collect qualitative data about teaching and learning activities related to tobacco control in June 2021. Descriptive statistics were used for data analysis, including inferential statistics regarding logistic regression.

RESULTS

Overall, 3.9% (95% CI: 3.1–4.6) of the students currently used e-cigarettes in the past 30 days. The significant factors that could explain 43.4% of e-cigarette use were predisposing factors: being male (adjusted odds ratio, AOR=1.8; 95% CI: 1.0–3.3), having a neutral attitude toward e-cigarette use (AOR=2.2; 95% CI: 1.1–4.5), and not believing that public health professionals should serve as non-smoking role models for clients and the general public (AOR=2.3; 95% CI: 1.2–4.0). The enabling factor was having tried tobacco products (AOR=40.7; 95% CI: 19.1–87.1), and the reinforcing factor was having three or more close friends who smoke cigarettes (AOR=3.2; 95% CI: 1.8–5.8).

CONCLUSIONS

Students’ behaviors should be modified through curriculum-based teaching and learning activities to develop negative attitudes toward e-cigarette smoking, increase students’ awareness as non-smoking role models, and establish smoke-free environments.

Tech, Sex, and E-cigarettes: The Gendering of Vape Promotion on Instagram

The promotion of vape products on social media has been implicated in increasing rates of e-cigarette usage, particularly among youth and young adults. While research has examined overall trends in vape-related content across a number of platforms, the role that social media "influencers" play in promoting vaping and potentially augmenting this public health crisis has been insufficiently explored. The present study examined 44,052 Instagram posts by 60 male presenting and 60 female presenting vape influencers to understand how influencer gender mediates the performance of vape culture online. Our textual and visual analysis of these influencers' posts over one year revealed significant bifurcations based on gender. Independent sample t-tests showed statistically significant gender differences in word frequency. Male-presenting influencers tended to emphasize their expertise with vape devices as technologies, while female-presenting influencers tended to focus on their own appearance. Further, factor analysis indicated six major categories of textual features, and multiple linear regression tests showed varying levels of user engagement with the different categories across both genders. Chi-square tests indicated that female-presenting influencers highlighted their own bodies in the visual content of their posts, whereas male presenting influencers often posted images of vape devices or their component parts alone. These findings suggest that gender presentation plays an important role in shaping vape influencers' promotional tactics and vape-related content on Instagram, and also provides insights into what kinds of content receive the most user engagement. This study can therefore help inform interventions to mitigate the impact of social media vape promotion.

A Systematic Review of E-Cigarette Marketing Communication: Messages, Communication Channels, and Strategies

Marketing plays a key role in increasing the popularity of e-cigarettes. We conducted a systematic review of the existing literature published between 2003 and 2019 in eight databases to describe e-cigarette marketing communication messages by communication channels and marketing communication strategies. Forty-one articles were included in the analysis after screening. Ten key messages were identified. Cessation and health-related benefits (each n = 31, 75.6%) were the most reported marketing communication messages, followed by sociability/lifestyle and use experience. The Internet (n = 32, 78.0%) was the most studied communication channel compared to print, TV/movie/radio, and point-of-sales (POS)/retail stores. The most studied marketing communication strategies were advertising (n = 28, 68.3%), followed by public relations and sales promotion. Published research studies reported consistent messages about e-cigarettes across communication channels and marketing communication strategies. Claims of smoking cessation and health-related benefits were widely identified in the existing literature. While therapeutic claims are prohibited, soft sell messages, such as social appeals, for which regulatory reach may be limited, may require educational campaigns. Internet marketing has attracted much attention, with limited studies on messages in print, TV/movie/radio, and POS/retail stores. The lack of studies of direct marketing messaging indicates a big gap between industry spending and academic research; more studies of messaging utilizing this strategy are needed.