An experimental study of messages communicating potential harms of electronic cigarettes

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

CONTEXT

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

METHODS

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

FINDINGS

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

CONCLUSION

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

Perceptions about levels of harmful chemicals in e-cigarettes relative to cigarettes, and associations with relative e-cigarette harm perceptions, e-cigarette use and interest

BACKGROUND AND AIMS

Exposure to chemicals contributes to harm from nicotine products, and e-cigarette communications often refer to chemicals. However, while e-cigarette studies commonly measure perceived harmfulness of e-cigarettes relative to cigarettes, few have assessed comparative perceptions about chemicals. This study measured perceived levels of harmful chemicals in e-cigarettes compared with cigarettes and associations with e-cigarette/cigarette relative harm perceptions, e-cigarette use and interest.

DESIGN, SETTING AND PARTICIPANTS

This was an on-line cross-sectional survey of adults/young adults from a nationally representative research panel in the United States conducted in January 2021. Participants were independent samples of 1018 adults who smoked cigarettes and 1051 young adult non-smokers (aged 18-29 years).

MEASUREMENTS

Participants were asked their perceptions of the level of harmful chemicals in e-cigarettes versus cigarettes (fewer/about the same/more/do not know), perceived harmfulness of using e-cigarette versus cigarettes (less/about the same/more/do not know) and their current e-cigarette use and use interest.

FINDINGS

Approximately 20% of all participants (18.1% of adult smokers, and 21.0% of young adult non-smokers) believed e-cigarettes contain fewer harmful chemicals than cigarettes, while 35.6% of adult smokers and 24.9% of young adult non-smokers responded 'do not know'. Participants more frequently reported 'do not know' to the chemicals item than the harm item. Approximately half (51.0-55.7%) of those who believed e-cigarettes contain fewer harmful chemicals also believed e-cigarettes are less harmful than cigarettes. Both beliefs were associated with higher odds of interest in using e-cigarettes [less harmful belief, odds ratio (OR) = 5.53, 95% confidence interval (CI = 2.93-10.43); fewer chemicals belief, OR = 2.45, 95% CI = 1.40-4.29] and past 30-day e-cigarette use (less harmful belief, OR = 2.53, 95% CI = 1.17-5.44; fewer chemicals belief, OR = 5.09, 95% CI = 2.31-11.19) for adults who smoke, but not young adult non-smokers.

CONCLUSIONS

In the United States, most adults who smoke cigarettes and young adult non-smokers do not appear to think that e-cigarettes have fewer harmful chemicals than cigarettes, and many are uncertain about how these levels compare.

Perceived effectiveness of objective elements of vaping prevention messages among adolescents

INTRODUCTION

In recent years, vaping prevention campaigns have proliferated in response to a surge of e-cigarette use among adolescents in the USA. To date, the research literature has provided minimal guidance as to what vaping prevention message elements have the greatest potential for discouraging vaping, are ineffective or have unintended negative effects. The purpose of the current study was to identify and test a large set of vaping prevention ads used by federal, state, local and non-governmental agencies, examining how objectively coded message elements of vaping prevention messages might affect youth.

METHODS

A convenience sample of adolescents (N=1501) completed an online survey with each participant rating seven randomly selected vaping prevention ads from a pool of 220 ads on perceived message effectiveness (PME) and vaping appeal. Ads were coded on 37 objective elements in three message categories: themes, imagery and other features. Analyses examined how objective elements predicted PME.

RESULTS

Addiction, chemicals, negative health symptoms and effects, and cigarette comparison themes were associated with higher PME, as were graphic images and warning symbols. Industry targeting, environmental impact, flavour themes, images of food and people's faces were associated with lower PME, as were hashtags, statistics and first-person language or the word 'teen'. Most elements were not associated with appeal, but ads with a flavour theme were associated with increased vaping appeal.

CONCLUSION

Promising vaping prevention messages focus on the adverse consequences of vaping, use negative imagery and avoid speaking for teens using their vernacular or perspective.

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

AIMS

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

METHOD

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

RESULTS

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

POLICY IMPLICATIONS

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

Perceived Message Effectiveness: Do People Need to Think About Message Effectiveness to Report the Message as Effective?

How people make perceived message effectiveness (PME) judgments remains mostly unexplored. This study assessed whether people need to spontaneously think about message effectiveness to report the message as effective on rating scales and investigated emotions as precursors to PME. After viewing one of four e-cigarette prevention messages, 1,968 adult current and former smokers and nonsmokers freely expressed thoughts about the messages in an open-ended question and answered close-ended PME items. Four expressed PME variables (positive message perceptions, negative message perceptions, positive effect perceptions, and negative effect perceptions) were coded (1 = present, 0 = absent) in the open-ended responses, and all were significantly associated with measured PME. Positive and negative emotions predicted both expressed and measured PME. Negative message perceptions was the only expressed PME construct that mediated the relationships between emotions and measured PME and outcomes (perceived risk and behavioral intentions). This suggests that messages may not need to induce effectiveness thoughts to be reported as effective, but thoughts of message ineffectiveness are a useful indicator deserving further research.

U.S. young adults' awareness of the Master Settlement Agreement and cigarette industry practices and their associations with electronic cigarette industry and health risk perceptions

BACKGROUND

The lawsuit that led to the U.S. Master Settlement Agreement (MSA) exposed the cigarette industry's deceptive marketing practices, which changed population perceptions about the cigarette industry and helped prevent cigarette smoking. The cigarette industry now owns many electronic cigarette (e-cigarette) companies and make their own e-cigarettes. Given that the MSA occurred in previous decades, many millennial and generation Z young adults may not know about the MSA and the cigarette industry's marketing practices. It is unknown whether awareness about the MSA and cigarette industry practices may influence these young adults' e-cigarette industry and e-cigarette health risk perceptions, which may inform e-cigarette prevention efforts.

METHODS

Cross-sectional data were collected from a U.S. sample of tobacco-naïve young adults, 18-30 years-old, susceptible to e-cigarette use (n = 1,329) through an online panel service in August 2021-January 2022. Participants reported their demographic characteristics, awareness of the MSA, awareness of cigarette industry practices, e-cigarette industry perceptions, and e-cigarette health risk perceptions. We examined the relationships between awareness of the MSA and cigarette industry practices with e-cigarette industry and e-cigarette health risk perceptions using multivariable linear regressions, adjusted for demographic characteristics.

RESULTS

Overall, 36.2%, 24.1%, and 39.3% of participants had heard of the MSA and knew a lot about it, had heard of the MSA, but did not know much about it, and did not hear of the MSA, respectively. On average, participants were aware of 5.2 (SD = 3.0) of the 11 cigarette industry practices included. Hearing about the MSA and knowing a lot about it and awareness of more cigarette industry practices were associated with less positive e-cigarette industry and higher e-cigarette health risk perceptions, whereas having heard of the MSA but not knowing much about it was associated with more positive e-cigarette industry and lower e-cigarette health risk perceptions.

CONCLUSIONS

Findings suggest that increasing comprehensive awareness of the MSA and cigarette industry practices may influence young adults' e-cigarette-related perceptions, and may importantly prevent detrimental information gaps about the cigarette industry. Future research should investigate the potential impact of increasing awareness of the MSA and cigarette industry practices in changing e-cigarette-related perceptions, which may help prevent e-cigarette use.

Association between Harmful and Addictive Perceptions of E-Cigarettes and E-Cigarette Use among Adolescents and Youth-A Systematic Review and Meta-Analysis

BACKGROUND

Recognising the association between the perceived risks of e-cigarettes and e-cigarette usage among youth is critical for planning effective prevention and intervention initiatives; thus, a systematic review and meta-analysis were performed.

METHODS

Fourteen databases were searched for eligible studies from the Inception of database until March 2022 to examine the effect estimates of the association between perceptions of harmfulness and addictiveness and overall e-cigarette usage among adolescents and youth.

RESULTS

The meta-analysis showed that in comparison to non-users, young people who were ever e-cigarette users were two times more likely to disagree that e-cigarettes are harmful (OR: 2.20, 95% CI: 1.41-3.43) and perceived e-cigarettes as less harmful than tobacco cigarettes (OR: 2.01, 95% CI 1.47-2.75). Youths who were ever e-cigarette users were also 2.3 and 1.8 times more likely to perceive e-cigarettes as less addictive (OR: 2.28, 95% CI: 1.81-2.88) or perceive e-cigarettes as more addictive (OR: 1.82, 95% CI: 1.22-2.73) than tobacco cigarettes, as compared with non-users. The subgroup analysis reported that adolescents were more likely to believe that e-cigarettes are less harmful than tobacco cigarettes, while youth users perceived otherwise.

CONCLUSION

the risk perceptions of e-cigarettes are associated with e-cigarette use among adolescents and youth and could be the focus of health promotion to prevent and curb the uptake of e-cigarettes among young people.

Tests for confounding with cigarette smoking in the association of E-cigarette use with respiratory disorder: 2020 National-Sample Data

Associations of e-cigarette use with respiratory disorder have been demonstrated but it has been unclear whether these are confounded by current or previous cigarette smoking. We address this question through studying different time frames for e-cigarette use and respiratory disorders in 2020 BRFSS data (N = 214,945). E-cigarette use and combustible cigarette smoking were classified into four categories: Participant never used either (Nonuse); used e-cigarettes/cigarettes but not in the past 30 days (Former Use), used in past 30 days on some days (Nondaily Use), or used past 30 days on all days (Daily Use). Contrasts for e-cigarette status and cigarette status (with nonuse as reference group) were entered with covariates in logistic regression with asthma or COPD as criterion. Stratified analyses of e-cigarette use were also performed for smokers and nonsmokers. In the total sample, results showed independent positive associations with both lifetime and current asthma for Former, Nondaily, and Daily e-cigarette use (mostly p < .0001) and the three cigarette indices. Significant positive associations with COPD were found for the three e-cigarette indices (p < .0001) and all the cigarette indices. Stratified analyses showed significant associations of e-cigarette use with respiratory disorder among nonsmokers as well as among smokers. We conclude that independent associations for former e-cigarette use (controlling for current/former smoking) and significant associations of e-cigarette use with respiratory disorder among nonsmokers indicate these associations are not confounded with cigarette smoking and suggest reverse causation is implausible. Findings for former use are discussed with reference to possible mechanisms including sensitization effects.

A Content Analysis of U.S. Adults' Open-Ended Responses to E-Cigarette Risk Messages

To better understand the processing of e-cigarette prevention messages, we conducted a content analysis of 1,968 participants' open-ended responses to one of four messages, which focused on industry manipulation (Big tobacco), financial and psychological cost of vaping (Can't afford), harmful chemicals in e-cigarettes (Formaldehyde), or uncertainty about the ingredients of e-liquids (Top secret). Health Belief Model (HBM) and perceived message effectiveness (PME) constructs were coded and the frequency of each variable was compared across message conditions. Among the HBM constructs, perceived health threat had the most mentions overall (38.8%). Self-efficacy of staying away from vaping had the fewest mentions across all messages (0.56%). For PME, participants more frequently mentioned message perceptions (15.75% positive message perceptions, 8.38% negative) than effect perceptions (3.46% positive effect perceptions, 1.37% negative). Big tobacco received the highest number of mentions for positive message perceptions and Formaldehyde received the highest number of mentions for positive effect perceptions. Future anti-vaping messages are recommended to address the efficacy element and to combine different themes to communicate harms of e-cigarettes.

Responses to e-cigarette health messages among young adult sexual minoritized women and nonbinary people assigned female at birth: Assessing the influence of message theme and format

BACKGROUND

Young adult sexual minority women (YSMW) report disproportionate e-cigarette (EC) use and low EC harm perceptions. Health messages that effectively communicate EC harms to YSMW are needed. We tested the effect of culturally targeted EC health messages with varying themes and image formats on attitudes and intentions to use ECs in this population.

METHODS

N = 501 YSMW and nonbinary people assigned female at birth (AFAB) aged 18-30 years-old completed an online experiment. Participants were randomized into a control or one of nine experimental conditions in a 3 (theme: harms, wellness, pride) by 3 (image format: individual, couple, cartoon) study design. We modeled associations between message condition and message effectiveness, discouragement from vaping, change in feelings toward vaping, perceived threat, and intentions to abstain from vaping.

RESULTS

Among YSMW and nonbinary people AFAB, harm and wellness themes discouraged vaping more than pride-themed messages (p's < 0.001). Harms messages resulted in worse feelings about vaping than wellness and pride messages (p's < 0.02). Images of couples were perceived as more effective than cartoon images (p = .008). Among current EC users, viewing images of individuals resulted in greater readiness to avoid ECs and higher intentions to abstain than the couple or cartoon conditions (p's < 0.001).

CONCLUSIONS

Message theme and image format were associated with YSMW and nonbinary people AFAB's EC attitudes and behavioral intentions. Future studies should evaluate how to optimize harms messages; including if wellness or pride messages can be re-framed to better affect EC use in this population.

A qualitative examination of e-cigarette use among California young adults during the EVALI outbreak

The 2019 outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) increased awareness of potential health risks associated with vaping among the general public. Little is known, however, about how unfolding information regarding EVALI affected knowledge, attitudes, and behaviors among e-cigarette users, particularly among young adults. This study describes attitudinal and behavioral responses to EVALI among young adult e-cigarette users. In October and November 2019, seven focus groups were held with college-going young adult tobacco users from two four-year public universities in California. Focus groups included questions regarding knowledge of and reaction to EVALI news, and how the news affected product use. Text from current e-cigarette users was extracted to develop individual phenomenological textural-structural descriptions of e-cigarette use for 38 individuals which were used to create a composite experience of e-cigarette use in light of EVALI. Experiences indicated that e-cigarette users were aware of information regarding EVALI and received information from numerous sources. Information was filtered for legitimacy of EVALI claims and causes of EVALI. Risk rationalizations were developed to assess potential harm of continued e-cigarette use and provided reasoning for behavioral responses to EVALI. The emerging harm associated with EVALI prompted e-cigarette users to engage in a cognitive process resulting in employment of a range of rationalities to justify continued use. These results suggest how environmental, cognitive, and behavioral factors may interact as young adults negotiate e-cigarette-related harms.

LGB Tobacco Control: Do Health Belief Model Constructs Predict Tobacco Use Intentions Differently between LGB and Heterosexual Individuals?

This research includes two studies testing whether the Health Belief Model (HBM) constructs predict tobacco use intentions differently between heterosexual and lesbian, gay, and bisexual (LGB) people. Focusing on cigarette smoking, Study 1 (n = 1808 U.S. adult current smokers) found that the perceived health threat and perceived benefits of smoking differently predicted intentions to continue smoking between heterosexual and LGB smokers. The perceived health threat of smoking had a weaker negative relationship and perceived benefits of smoking had a stronger positive relationship with smoking intentions among LGB smokers than heterosexual smokers. Focusing on vaping, Study 2 (n = 2801 U.S. adults) found that the perceived health threat and perceived barriers of vaping differentially predicted vaping intentions between heterosexual and LGB individuals. The perceived health threat of vaping only negatively predicted vaping intentions among heterosexual people. Perceived barriers to vaping had a stronger negative relationship with intentions to vape among LGB people than among heterosexual people. Our finding suggests that compared to perceptions of tobacco-related health consequences (perceived heath threat), behavioral perceptions (perceived benefits and barriers) may have stronger impacts on tobacco use intentions among LGB people. Thus, efforts focusing on reducing tobacco-related disparities among the LGB community should address perceived benefits and barriers of tobacco use.

Trend Analysis of Head and Neck Neoplasms between 2012-2018 in Patients Residing in Al-Madinah, Saudi Arabia: A Retrospective Study

Objectives  This study sought to present a view of head and neck neoplasms (HNN) prevalence with specific focus on sociodemographic determinants in Al-Madinah Province, Saudi Arabia.

Materials and Methods  This was a hospital-based retrospective study based on retrieval of histopathological data for a period of 6 years between 2012 and 2018. Data was collected from the archives of the Oral and Maxillofacial Pathology Laboratory at King Fahad Hospital (the only referral center for biopsy services) in Al-Madinah City.

Statistical Analysis  An independent t -test and/or nonparametric (Mann–Whitney U test, chi-squared test) tests were used to determine the differences between groups. Statistical significance was set at the p -value < 0.05.

Results  Out of 96 patients, a total of 58 patients had valid biopsy data with preoperative diagnosis. Over three quarters of the cases ( n = 44) were benign with only 24% were malignant. Males were more likely to be diagnosed with a benign tumor than females (54.5 vs. 45.6%, respectively), and malignancy was also more common in males (64.3 vs. 24.1). A significant difference was found in relation to mean age of older patients who were more likely to be diagnosed with malignant tumors ( p = 0.001).

Conclusions  The findings suggest that most of biopsied HNN cases are benign neoplasms. Age is a significant risk factor for head and neck malignancy in this region. Delays in diagnosis of HNN need to be explored.