Associations of attitudes towards electronic cigarettes with advertisement exposure and social determinants: a cross sectional study

The influence of social media and video-on-demand platforms on the appeal and consumption of tobacco and emerging tobacco products: A cross-sectional study

INTRODUCTION

Digital platforms serve as an avenue for the tobacco industry to promote both conventional tobacco and emerging products, with a notable focus on capturing the attention of young people through sophisticated marketing campaigns. This research aims to analyze the prevalence of different advertising strategies on digital platforms and to assess the impact of exposure to these strategies on the probability of use initiation and increased consumption of conventional tobacco and new tobacco products among young Spaniards.

METHODS

An online survey was conducted on a representative sample of 1730 young Spaniards aged 16-21 years in November 2022 using a comprehensive approach, considering all possible relevant factors and perspectives regarding the issue of the study. A descriptive analysis and two adjusted logistic regression models were employed to explore the association of exposure to digital platforms with the likelihood of conventional tobacco and new tobacco product use among this population.

RESULTS

Among the participants, 83.2% reported witnessing individuals smoking, 61.6% observed identifiable logos or explicit advertisements, and 77.6% encountered indirect product placement on social media. Notably, exposure to conventional tobacco product placement (AOR=1.71; 95% CI: 1.27-2.30) emerged as the variable most significantly associated with an increased probability of tobacco use. Furthermore, exposure to advertising related to new tobacco products (AOR=2.47; 95% CI: 1.90-3.21) was linked to a heightened likelihood of subsequent use. Similarly, the direct promotion of these novel products is also associated with a higher probability of conventional tobacco use (AOR=1.58; 95% CI: 1.21-2.07).

CONCLUSIONS

A reciprocal impact was identified, with the promotion of vaping being associated with an elevated probability of engaging in conventional tobacco smoking. Urgent attention is warranted for formulating public policies to mitigate the adverse effects of such insidious indirect advertising practices on digital platforms.

Relative increases in direct-to-consumer menthol ads following 2020 FDA guidance on flavoured e-cigarettes

OBJECTIVE

To examine potential changes in email and direct mail advertisements for flavoured e-cigarettes following the 2020 Food and Drug Administration (FDA) flavour guidance.

METHODS

Digital copies of e-cigarette advertisements were obtained from Mintel Comperemedia (November 2019-May 2020) and coded for the presence of flavours. Χ2 tests were used to determine changes in the prevalence of email and direct mail advertisements for e-cigarettes with menthol, non-menthol and no flavours.

RESULTS

Following FDA guidance, the relative proportion of menthol-flavoured e-cigarette advertisements sent via email significantly increased from 22.5% to 52.2%. No changes were found for e-cigarette advertisements mentioning no flavours, nor non-menthol-flavoured e-cigarettes, sent via email or direct mail.

CONCLUSIONS

The 2020 FDA flavour guidance was followed by an increased proportion of direct-to-consumer email advertisements of menthol-flavoured e-cigarette products.

E-cigarettes may serve as a gateway to conventional cigarettes and other addictive drugs

Electronic cigarettes (e-cigarettes) are devices that allow the user to inhale nicotine in a vapor, and are primarily marketed as a means of quitting smoking and a less harmful replacement for traditional cigarette smoking. However, further research is needed to determine if vaping nicotine via e-cigarettes can be effective. Conversely, nicotine has been considered a gateway drug to alcohol and other addictive drugs and e-cigarettes containing nicotine may have the same effects. Previous reports have shown that e-cigarette use may open the gate for the use of other drugs including conventional cigarettes, cannabis, opioids, etc. The increasing prevalence of e-cigarettes, particularly among youth and adolescents in the last decade have led to an increase in the dual use of e-cigarettes with alcohol, cannabis, and other illicit drug use like heroin and 3-4-methylenedioxymethamphetamine (MDMA). The advent of e-cigarettes as a device to self-administer addictive agents such as cocaine and synthetic cathinones may bring about additional adverse health effects associated with their concurrent use. This review aims to briefly describe e-cigarettes and their different generations, and their co-use with other addictive drugs as well as the use of the device as a tool to self-administer addictive drugs, such as cocaine, etc.

Knowledge, beliefs, attitude, and practices of E-cigarette use among dental students: A multinational survey

Background

E-cigarette use is a trend worldwide nowadays with mounting evidence on associated morbidities and mortality. Dentists can modify the smoking behaviors of their patients. This study aimed to explore the knowledge, beliefs, attitude, and practice of E-cigarette use among dental students.

Materials and methods

This multinational, cross-sectional, questionnaire-based study recruited undergraduate dental students from 20 dental schools in 11 countries. The outcome variable was current smoking status (non-smoker, E-cigarette user only, tobacco cigarette smoker only, dual user). The explanatory variables were country of residence, sex, age, marital status, and educational level. Multiple linear regression analysis was performed to explore the explanatory variables associated with E-cigarette smoking.

Results

Of the 5697 study participants, 5156 (90.8%) had heard about E-cigarette, and social media was the most reported source of information for 33.2% of the participants. For the 5676 current users of E-cigarette and/or tobacco smoking, 4.5% use E-cigarette, and 4.6% were dual users. There were significant associations between knowledge and country (P< 0.05), educational level (B = 0.12; 95% CI: 0.02, 0.21; P = 0.016) and smoking status (P< 0.05). The country of residence (P< 0.05) and smoking status (P< 0.05) were the only statistically significant factors associated with current smoking status. Similarly, there were statistically significant associations between attitude and country (P< 0.05 for one country only compared to the reference) and history of previous E-cigarette exposure (B = -0.52; 95% CI: -0.91, -0.13; P = 0.009). Also, the practice of E-cigarettes was significantly associated with country (P< 0.05 for two countries only compared to the reference) and gender (B = -0.33; 95% CI: -0.52, -0.13; P = 0.001).

Conclusion

The knowledge of dental students about E-cigarette was unsatisfactory, yet their beliefs and attitudes were acceptable. Topics about E-cigarette should be implemented in the dental curriculum.

The Mediating Effect of E-Cigarette Harm Perception in the Relationship between E-Cigarette Advertising Exposure and E-Cigarette Use

Exposure to e-cigarette advertising is associated with e-cigarette use among young people. This study examined the mediating effect of e-cigarette harm perception on the above relationship. Cross-sectional survey data were collected from 2112 college students in New York City in 2017-2018. The analytic sample comprised 2078 participants (58.6% females) who provided completed data. Structural equal modeling was performed to examine if e-cigarette harm perception mediated the relationship between e-cigarette advertising exposure (via TV, radio, large signs, print media, and online) and ever e-cigarette use and susceptibility to e-cigarette use. About 17.1% of participants reported ever e-cigarette use. Of never users, 17.5% were susceptible to e-cigarette use. E-cigarette advertising exposure was mainly through online sources (31.5%). Most participants (59.4%) perceived e-cigarettes as equally or more harmful than cigarettes. Advertising exposure showed different effects on e-cigarette harm perception depending on the source of the advertising exposure, but perceiving e-cigarettes as less harmful than cigarettes was consistently associated with e-cigarette use and susceptibility. Low harm perception mediated the association between advertising exposure (via online, TV, and radio) and ever e-cigarette use and between online advertising exposure and e-cigarette use susceptibility. Regulatory actions are needed to address e-cigarette marketing, particularly on the Internet.

The association of adolescent e-cigarette harm perception to advertising exposure and marketing type

BACKGROUND

Despite controversy over their possible health consequences, manufacturers of e-cigarettes employ a variety of marketing media to increase their popularity among adolescents. This study analyzed the relationship between adolescent e-cigarette harm perception and five types of e-cigarette advertising exposures: social media, radio, billboard, newspaper, and television.

METHODS

This study used data from Wave 4.5 of the Population Assessment of Tobacco and Health Study (PATH). PATH collects demographic data and interview individuals about issues pertaining to tobacco use, health outcomes, attitudes, and behaviors. This study applied factor analysis to three individual PATH harm perception items to develop a composite harm perception score. Using linear regression, the study explored the relationship of harm perception and participant responses to their recalled viewing of five different types (i.e., newspaper, radio, billboard, television and social media) of advertisements within the past 30 days. A second analysis explored if adjusting for exposure to anti-tobacco messaging and environmental factors such as family approval mitigated the association of harm perception and advertisement types.

RESULTS

The study sample consisted of 12,570 (weighted N = 23,993,149) individuals aged 12 to 17 years old. Unadjusted past 30-day exposure to newspaper, radio, billboard, and social media advertising all correlated with a reduced harm perception, but only the associations for newspaper and social media were statistically significant (p<0.05). After adjusting for environmental support factors, exposure to warning labels, and anti-tobacco advertisements, the analysis yielded statistically significant associations between increased e-cigarette harm perception and exposure to radio, billboard, and television advertisements (p<0.05). Adjusting for covariates also reduced the association of marketing and harm perception for all forms of media.

CONCLUSION

E-cigarette advertising influences adolescent perceptions of harm in e-cigarette use, particularly for social media and newspaper advertisements. This association weakens when adjusted for covariates such as environmental support and exposure to anti-tobacco marketing. These findings provide evidence for policy makers to continue anti-tobacco marketing and incorporate environmentally supportive strategies such as holistic, family-centered educational approaches to reduce e-cigarette use among adolescents.

Exposure to e-cigarette advertising, attitudes, and use susceptibility in adolescents who had never used e-cigarettes or cigarettes

Background

Tobacco advertisements have been banned in Hong Kong, but low intensity e-cigarette (EC) advertising can still be found in various media outlets. We investigated the associations between exposure to EC advertising and susceptibility to EC use in adolescents who had never used cigarettes or ECs, with potential mediation by attitudes towards ECs and the tobacco industry.

Methods

The School-based Smoking Survey 2016/17 assessed exposure to EC advertising in the past 30 days, attitudes towards ECs and the tobacco industry, susceptibility to EC use, and other covariates. Generalised linear mixed models and multiple mediation analysis methods were used in data analyses.

Results

Among 7082 students (mean age 14.9 years), 28.8% reported exposure to EC advertising. Exposure was associated with being uncertain about the harm of EC use, being tolerant towards ECs, believing the tobacco industry is respectable, and being susceptible to EC use; the magnitudes of these associations increased with the number of types of advertising exposed (0, 1, and ≥ 2) (all p-values < 0.01). These attitudinal factors were in turn associated with EC use susceptibility (all p-values < 0.001). The perception that tobacco companies make youth smoke was not associated with the advertising exposure or EC use susceptibility. Of the total effects of EC advertising on use susceptibility, only 16.6% were mediated by attitudinal factors: perceived harm (3.1%), attitudes towards ECs (8.2%), and attitudes towards the tobacco industry (4.9%).

Conclusions

Even exposure to low intensity EC advertising was associated with susceptibility to EC use in adolescents who had never used cigarettes or ECs. The association was weakly mediated by tolerant attitudes towards ECs and the tobacco industry. The government should reinforce the regulations on EC advertising to protect adolescent health.

Knowledge, Attitudes, and Perceptions of Young Adults About Electronic Nicotine Delivery Systems in the United States: An Integrative Review

BACKGROUND

The causal link between cigarettes and cardiovascular disease is well known. The long-term effects of e-cigarettes are yet unknown, although early studies show biomarkers indicating inflammation and damage to endothelial cells associated with later development of cardiovascular disease. With the rapid rise in e-cigarette use, especially in young adults, it is imperative that health professionals understand the knowledge, perceptions, and motivations for use among young adults.

OBJECTIVES

The purpose of this integrative review is to explore existing literature on young adults' knowledge, attitudes, values, and perceptions about e-cigarettes, as well as the social norms they experience.

METHODS

The Whittemore and Knafl model for integrative review guided the methodology. Three databases were searched from January 2010 through December 2018. The study selection process followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion and exclusion criteria were applied. Studies were evaluated for quality and strength. Key themes were extracted, coded, and synthesized.

RESULTS

Seventy-one full-text studies were assessed for inclusion criteria; 15 articles were included, coded, and analyzed for quality and thematic content. Current e-cigarette users represented just 3% to 35% of study participants. Three themes arose from a synthesis of the literature: "Is it bad for me?," "I just like it," and "Is it cool or not?"

CONCLUSIONS

Young adults are not armed with the accurate knowledge to make informed choices about using e-cigarettes. E-cigarette users are understudied and tend to value appearance and physical sensation over health. Social norms related to e-cigarette use are linked to perception of identity and the current technology-focused culture.

Associations between public e-cigarette use and tobacco-related social norms among youth

IMPORTANCE

E-cigarette use in public places may renormalise tobacco use.

OBJECTIVE

To measure associations between e-cigarette use in public places and social norms among youth.

DESIGN

Cross-sectional survey.

SETTING

School-based.

PARTICIPANTS

24 353 never tobacco users in US 6th-12th grades who completed the 2016-2017 National Youth Tobacco Surveys.

EXPOSURE

Individuals were classified as exposed in public places within the past 30 days to: (1) neither e-cigarette secondhand aerosol (SHA) nor combustible tobacco secondhand smoke (SHS); (2) SHA only; (3) SHS only; and (4) both SHA and SHS.

OUTCOMES

Outcomes were overestimation of peer e-cigarette use (a measure of descriptive norms), harm perception and susceptibility. Data were analysed using descriptive statistics and logistic regression (p<0.05).

RESULTS

Overall prevalence of SHS and SHA exposure in public places was 46.6% and 18.3%, respectively. SHA exposure in public places was associated with increased odds of overestimating peer e-cigarette use (adjusted OR (AOR): 1.83; 95% CI 1.29 to 2.58) and decreased odds of perceiving e-cigarettes as harmful (AOR: 0.63; 95% CI 0.51 to 0.79), compared with those exposed to neither emission. SHA exposure in public places was also associated with increased susceptibility to using e-cigarettes (AOR: 2.26; 95% CI 1.82 to 2.81) and cigarettes (AOR: 1.51; 95% CI 1.20 to 1.90). E-cigarette harm perception was lower among students in jurisdictions with no comprehensive clean indoor air laws (AOR: 0.79; 95% CI 0.71 to 0.88) or cigarette-only laws (AOR: 0.88; 95% CI 0.78 to 0.99) than in those prohibiting both cigarette and e-cigarette use in public places.

CONCLUSIONS

Prohibiting both e-cigarette and cigarette use in public places could benefit public health.

Electronic cigarettes: Emerging trends and research hotspots

INTRODUCTION

Research on electronic cigarettes is an emerging field, with the number of articles in this field noted to have grown exponentially over recent years. We used a bibliometric analysis method (co-word analysis) to analyze the emerging trends and research hotspots in this field.

METHODS

Publication data on electronic cigarettes from 2010 to 2018 were retrieved and downloaded from the PubMed database. Theme trends and knowledge structures were analyzed on the relevant research fields of electronic cigarettes by using a biclustering analysis, strategic diagram analysis, and social network analysis methods. Research hotspots were extracted and compared from three periods.

RESULTS

Core topics that have continuously develop between the years 2010 and 2018 include: tobacco use cessation devices; tobacco products; tobacco use cessation devices/adverse effects; smoking prevention and adverse effects; electronic nicotine delivery systems/economics; and public health. Some currently undeveloped topics that could be considered as new future research directions include: tobacco use disorder/therapy; tobacco use disorder/epidemiology; students/psychology; students/statistics and numerical data; adolescent behavior/psychology; nicotine/toxicity; nicotinic agonists/administration and dosage; and electronic nicotine delivery systems/legislation and jurisprudence.

CONCLUSIONS

Results suggest that some currently immature topics in strategic coordinates and emerging hotspots in social network graphs can be used as future research directions.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Implications

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

Knowledge about E-Cigarettes and Tobacco Harm Reduction among Public Health Residents in Europe

Introduction: Although electronic cigarettes (e-cigarettes) and other tobacco-related products are becoming widely popular as alternatives to tobacco, little has been published on the knowledge of healthcare workers about their use. Thus, the aim of this study was to elicit the current knowledge and perceptions about e-cigarettes and tobacco harm reduction (THR) among medical residents in public health (MRPH). Material and Methods: A Europe-wide cross-sectional study was carried out amongst MRPH from the countries associated with the European Network of MRPH from April to October 2018 using an online questionnaire. Results: 256 MRPHs agreed to participate in the survey. Approximately half the participants were women (57.4%), with a median age of 30 years, and were mainly Italian (26.7%), Spanish (16.9%) and Portuguese (16.5%). Smoking prevalence was 12.9%. Overall, risk scores significantly differed for each investigated smoking product when compared with e-cigarettes; with tobacco cigarettes and snus perceived as more risky, and nicotine replacement therapy (NRT) and non-NRT oral medications seen as less risky (p < 0.01 for all). Regarding the effects of nicotine on health, the vast majority of MRPHs associated nicotine with all smoking-related diseases. Knowledge of THR was low throughout the whole sample. Conclusions: European MRPH showed a suboptimal level of knowledge about e-cigarettes and THR. Training programs for public health and preventive medicine trainees should address this gap.

E-cigarettes, alcohol use, and mental health: Use and perceptions of e-cigarettes among college students, by alcohol use and mental health status

INTRODUCTION

Electronic cigarettes (e-cigarettes) are popular among college students, who display risky alcohol use patterns. However, little is known about patterns of co-use of e-cigarettes and alcohol. Further, relationships between e-cigarette use and mental illness among college students are unclear.

METHODS

College student participants (N = 631) at a northeastern U.S. university were invited via email to participate in a survey about e-cigarettes and alcohol use. Mental health was self-reported diagnosis of psychiatric (depression, bipolar disorder, schizophrenia, PTSD, anxiety disorder, personality disorder), and substance (alcohol and other drug) use disorders. Current use of e-cigarette, combustible cigarette, and other tobacco products were assessed via self-reported past 30-day use frequency. Alcohol consumption was assessed via number of self-reported standard alcoholic beverages consumed during a typical drinking episode. Participants also reported regarding co-use of alcohol, e-cigarettes and/or combustible cigarettes. Participants were categorized as non-drinkers, moderate drinkers or binge drinkers, and associations between e-cigarette use, drinking patterns and mental health diagnoses were examined.

RESULTS

E-cigarette use was associated with drinking alcohol χ2 = 18.62, p < .001, and binge drinking (vs. moderate drinking) χ2 = 12.20, p < .001. Students who had tried e-cigarettes reported drinking more alcohol per episode (χ2 = 15.94, p < .001). E-cigarette use was more prevalent among those with psychiatric and substance use disorders χ2 = 11.65, p < .001.

CONCLUSIONS

Drinking college students (especially binge drinkers) and those with mental illness may have heightened risks for e-cigarette use. More research is needed to elucidate relationships between risky alcohol and/or nicotine use and mental illness, and to guide appropriate prevention and intervention efforts for vulnerable college students.

Effect of e-cigarette advertisement exposure on intention to use e-cigarettes in adolescents

INTRODUCTION

With the growth of electronic cigarettes use, curiosity about and experimentation with these products has increased among adolescents. The purpose of the present study was to evaluate the moderating effect of e-cigarette advertisement (ad) exposure on the relation between perceptions of use and intentions to use in youth.

METHODS

Multiple regression analyses utilizing data from the 2014 National Youth Tobacco Survey (N = 17,286) were used to evaluate the effect of ad exposure, perceived harmfulness, barriers, and benefits of e-cigarette use on intentions to use among youth who had never used e-cigarettes.

RESULTS

Models for non-smokers accounted for 15.5% of the variance in intention to use (R² = 0.155, F (15) = 187.0, p < 0.001). Results demonstrate that an increase in the number of exposures to e-cigarette ads was associated with an increase in intent to use (b = 0.039, t = 7.4, p < 0.001). Models also demonstrated significant interactions between ad exposure and perceptions of use on future intention to use. For smokers, models explained 11.1% of the variance in intention to use (R² = 0.111, F (15) = 3.1, p < 0.001). Ad exposure had a non-significant effect on intention to use e-cigarettes (b = -0.010, t = -0.2, p = 0.859). In smokers, ad exposure did not significantly affect the association between perceptions of use and intention to use.

CONCLUSIONS

Ads are most effective at attracting non-smoking youth as new users rather than promoting product switching in young cigarette smokers.

E-cigarette advertising exposure in e-cigarette naïve adolescents and subsequent e-cigarette use: A longitudinal cohort study

OBJECTIVE

Electronic (E-) cigarettes are one of the most popular tobacco products used by adolescents today. This study examined whether exposure to advertisements in (1) social networking sites (Facebook, Twitter, YouTube, Pinterest/Google Plus), (2) traditional media (television/radio, magazines, billboards), or (3) retail stores (convenience stores, mall kiosks, tobacco shops) was associated with subsequent e-cigarette use in a longitudinal cohort of adolescents.

METHODS

Data were drawn from longitudinal surveys conducted in fall 2013 (wave 1) and spring 2014 (wave 2) of a school-based cohort attending 3 high schools and 2 middle schools in Connecticut. Adolescents were asked about tobacco use behaviors and where they had recently seen e-cigarette advertising at wave 1. We used logistic regression to determine whether advertising exposure at wave 1 increased the odds of e-cigarette use by wave 2, controlling for demographics and cigarette smoking status at wave 1.

RESULTS

Among those who have never used e-cigarettes in wave 1 (n = 1742), 9.6% reported e-cigarette use at wave 2. Multivariate logistic regression demonstrated that exposure to e-cigarette advertising on Facebook (OR 2.12 = p < 0.02) at wave 1, but not other venues, significantly increased the odds of subsequent e-cigarette use wave 2. Age, white race, and cigarette smoking at wave 1 also was associated with e-cigarette use at wave 2.

CONCLUSION

This study provides one of the first longitudinal examinations demonstrating that exposure to e-cigarette advertising on social networking sites among youth who had never used e-cigarettes increases the likelihood of subsequent e-cigarette use.

Discordance between perceived and actual tobacco product use prevalence among US youth: a comparative analysis of electronic and regular cigarettes

IMPORTANCE

Two components of social norms-descriptive (estimated prevalence) and injunctive (perceived acceptability)-can influence youth tobacco use.

OBJECTIVE

To investigate electronic cigarettes (e-cigarette) and cigarette descriptive norms and measure the associations between overestimation of e-cigarette and cigarette prevalence and tobacco-related attitudes and behaviours.

DESIGN

Cross-sectional.

SETTING

School-based, using paper-and-pencil questionnaires.

PARTICIPANTS

US 6th-12th graders participating in the 2015 (n=17 711) and 2016 (n=20 675) National Youth Tobacco Survey.

EXPOSURE

Students estimated the percent of their grade-mates who they thought used e-cigarettes and cigarettes; the discordance between perceived versus grade-specific actual prevalence was used to categorise students as overestimating (1) neither product, (2) e-cigarettes only, (3) cigarettes only or (4) both products.

OUTCOMES

Product-specific outcomes were curiosity and susceptibility (never users), as well as ever and current use (all students). Descriptive and multivariable logistic regression analyses were performed. Statistical significance was at P<0.05. Data were weighted to be nationally representative.

RESULTS

More students overestimated cigarette (74.0%) than e-cigarette prevalence (61.0%; P<0.05). However, the associations between e-cigarette-only overestimation and e-cigarette curiosity (adjusted OR (AOR)=3.29), susceptibility (AOR=2.59), ever use (AOR=5.86) and current use (AOR=8.15) were each significantly larger than the corresponding associations between cigarette-only overestimation and cigarette curiosity (AOR=1.50), susceptibility (AOR=1.54), ever use (AOR=2.04) and current use (AOR=2.52). Despite significant declines in actual e-cigarette use prevalence within each high school grade level during 2015-2016, perceived prevalence increased (11th and 12th grades) or remained unchanged (9th and 10th grades).

CONCLUSIONS

Four of five US students overestimated peer e-cigarette or cigarette use. Counter-tobacco mass media messages can help denormalise tobacco use.

The Effects of Digital Marketing of Unhealthy Commodities on Young People: A Systematic Review

The marketing of unhealthy commodities through traditional media is known to impact consumers’ product attitudes and behaviors. Less is known about the impacts of digital marketing (online promotional activities), especially among young people who have a strong online presence. This review systematically assesses the relationship between digital marketing and young people’s attitudes and behaviors towards unhealthy commodities. Literature was identified in June 2017 by searches in six electronic databases. Primary studies (both qualitative and quantitative) that examined the effect of digital marketing of unhealthy food or beverages, alcohol and tobacco products on young people’s (12 to 30 years) attitudes, intended and actual consumption were reviewed. 28 relevant studies were identified. Significant detrimental effects of digital marketing on the intended use and actual consumption of unhealthy commodities were revealed in the majority of the included studies. Findings from the qualitative studies were summarized and these findings provided insights on how digital marketing exerts effects on young people. One of the key findings was that marketers used peer-to-peer transmission of messages on social networking sites (e.g., friends’ likes and comments on Facebook) to blur the boundary between marketing contents and online peer activities. Digital marketing of unhealthy commodities is associated with young people’s use and beliefs of these products. The effects of digital marketing varied between product types and peer endorsed marketing (earned media) may exert greater negative impacts than owned or paid media marketing.