E-cigarette Marketing Exposure and Subsequent Experimentation Among Youth and Young Adults

A comprehensive content analysis of 104 Chinese electronic cigarette manufacturing enterprise official websites

OBJECTIVE

The goal was to analyse website content of Chinese electronic (e) cigarette manufacturing enterprises and understand the marketing strategies to provide evidence for decision-makers to regulate manufacturers.

METHODS

Through QCC.com, one of the largest enterprise information query platforms in China, we identified 104 official manufacturer websites in 2021. A codebook including 6 sections with 31 items was developed and all webpages were coded separately by two trained researchers.

RESULTS

Over half of the websites (56.7%) did not have age verification for entry. Thirty-two (30.8%) websites had no restriction for minors to use or purchase e-cigarettes, and 79 (76.0%) had no health warning. Overall, 99 websites (95.2%) displayed their products, and 72 (69.2%) displayed e-flavours. The most frequently used descriptions of products included good taste (68.3%), positive mood (62.5%), leakage resistance (56.7%), enjoyment (47.1%), reduced harm (45.2%), alternatives to cigarettes (43.3%) and long battery life (42.3%). Additionally, 75 websites (72.1%) provided contact information on different channels, including WeChat (59.6%), Weibo (41.3%), Facebook (13.5%), Instagram (12.5%) and brand apps (2.9%). Manufacturers provided investment and franchise information (59.6%) and offline store information (17.3%). In addition, 41.3% websites included content regarding corporate social responsibility.

CONCLUSIONS

Chinese e-cigarette manufacturers' official websites have become a platform for presenting product and brand information, establishing online and offline marketing loops, and displaying corporate social responsibility with weak age restrictions on access and a lack of health warnings. The Chinese government should implement strict regulatory measures on e-cigarette enterprises.

Associations between social media engagement and young adults' subsequent onset of ENDS dependence symptoms one year later

BACKGROUND

Young adults are more vulnerable than older adults to engagement with online tobacco marketing and to the use of electronic nicotine delivery systems (ENDS) products. Our study examined the longitudinal associations between engagement with pro- and anti-tobacco information on social media (SM) and young adults' subsequent onset of symptoms of dependence on ENDS products one year later, which remain unclear.

METHODS

Participants were college students in the Marketing and Promotions Across Colleges in Texas study. We analyzed data collected in spring 2018 (wave 8, baseline) and spring 2019 (wave 9), which involves 1,764 college students (Mean age = 24.48, 34.8% White) who reported having ever used any ENDS products but no ENDS dependence symptoms at baseline. Logistic regression analyses were conducted to examine the associations between pro- and anti-engagement with tobacco information at baseline and onset of ENDS dependence symptoms at one-year follow-up, controlling for baseline sociodemographic characteristics and tobacco smoking status. We also examined participant sex and depressive symptoms as moderators of the aforementioned associations.

RESULTS

Engagement with both pro- (Odds Ratio = 1.73, p < 0.05) and anti- (Odds Ratio = 1.36, p < 0.05) tobacco information at baseline predicted the subsequent onset of symptoms of dependence on ENDS products one year later. The association between pro-engagement and subsequent onset of ENDS dependence symptoms was stronger among females than males (Exp(β) = 3.21, p < 0.05). Depressive symptomology did not moderate any of the associations.

CONCLUSIONS

Findings suggest that engaging with tobacco information on SM, regardless of its valence, serves as a risk factor for the development of subsequent dependence symptoms among young adult ever ENDS users. Considering the uncertainty of ENDS products' health effects, regulation of SM is encouraged to reduce young adults' (re)posting thoughts or comments about the advantages of ENDS products.

The Development and Testing of a Point-of-Sale E-Cigarette Health Communication Campaign

Adolescents and young adults continue to use e-cigarettes, and communication campaigns are needed to decrease use among these populations. We developed and tested a point-of-sale communication campaign focused on e-cigarette chemical exposure. We developed messages based on formative research and tested them (versus text-only messages) in a nationally-representative online survey among adolescents and young adults (16-25) (Phase 1). Based on survey findings, we selected a message focused on nicotine and brain development for the point-of-sale trial (Phase 2). We then conducted a cluster-randomized trial at six gas stations with convenience stores, randomly assigned to the intervention (messages displayed) or no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 participants (ages 16-25) per store, at baseline and a four-week follow-up. Phase 1 included 1,636 participants in the online study. Intervention messages were rated as more attention grabbing than plain text messages (p < .05), though were rated similarly on other outcomes. Exposure to intervention messages resulted in larger changes from pre- to posttest for beliefs about addiction and relative harms versus cigarettes (p < .05). Phase 2 included 586 participants in the point-of-sale study. Real-world campaign exposure was low (31.8%), and no differences were found between conditions. E-cigarette prevention messages focused on nicotine's impact on brain development show promise. However, garnering attention for communication campaigns in saturated point-of-sale environments, often dominated by tobacco advertising, is challenging. Future efforts should utilize additional communication channels to directly target adolescents and young adults.

Factors associated with intentions to quit vaping and quit attempts among Adolescents: A structural equation modeling approach

OBJECTIVES

Previous youth tobacco research has identified multiple factors relating to intentions to quit vaping and quit attempts among current e-cigarette users in adolescents. The pathways in the complex associations with vaping cessation behaviors remain unclear.

METHODS

Using data from the 2022 National Youth Tobacco Survey (NYTS) (grades 6-12), structural equation models (SEMs) are developed to examine the associations of social environment, vaping risk perceptions, e-cigarette marketing, vaping characteristics, and demographics with two outcome measures - intentions to quit vaping and past year quit attempts among current e-cigarette users.

RESULTS

The national sample of current e-cigarette users (n = 2,701) consisted of 52.7 % females, 47.0 % non-Hispanic Whites, 80.1 % high school students, and 56.2 % heterosexual individuals. Among them, 70.2 % reported intentions to quit vaping and 66.3 % reported past year quit attempts. The protective factor for quit intentions was vaping risk perceptions (p < 0.001). Risk factors included e-cigarette marketing (p = 0.04), dual use of e-cigarettes and other tobacco products (p = 0.003), vaping due to feeling anxious or stressed (p = 0.01), vaping for nicotine buzz (p = 0.002), nicotine dependence (p = 0.02), identifying as Gay or Lesbian (p < 0.001), bisexual (p = 0.03), or Hispanic (p = 0.04). Similar associations were observed with quit attempts except that e-cigarette marketing, vaping due to feeling anxious or stressed, vaping dependence, and identifying as Hispanic were not significant. Besides, high vaping frequency (p < 0.001), grade level (p < 0.001) and not sure about sexual orientation (p = 0.01) were also negatively associated with quit attempts.

CONCLUSIONS

This study provided insights into factors influencing vaping cessation outcomes among adolescent current e-cigarette users. Developing tailored vaping cessation programs based on these findings could enhance quit success.

Associations between e-cigarette marketing exposure and vaping nicotine and cannabis among U.S. adults, 2021

INTRODUCTION

Little is known about the influence of e-cigarette marketing on cannabis vaping behaviors. This study examined the associations between e-cigarette marketing exposure and nicotine and cannabis vaping among adults.

METHODS

This cross-sectional study included a U.S. nationally representative sample of adults from the Wave 6 survey of the Population Assessment of Tobacco and Health Study. We used multinomial logistic regressions to examine the associations between past 30-day e-cigarette marketing exposure and past 30-day vaping behavior (sole- and dual-vaping of nicotine and cannabis) overall and stratified by age.

RESULTS

Overall, 52.0 % of respondents reported e-cigarette marketing exposure, and 89.8 %, 5.6 %, 3.2 %, and 1.4 % reported no vaping, sole-nicotine vaping, sole-cannabis vaping, and dual-vaping, respectively. E-cigarette marketing exposure was associated with increased odds of reporting sole-cannabis vaping versus no vaping (adjusted risk ratio [aRR], 1.31; 95 % confidence interval [CI], 1.09-1.57) and dual-vaping versus no vaping (aRR, 1.26; 95 % CI, 1.01-1.57). This association was found among those aged 18-24 and 25-34 years. It was also associated with increased odds of reporting sole-cannabis vaping versus sole-nicotine vaping (aRR, 1.28; 95 % CI, 1.04-1.58). This association was found among those aged 18-24 years.

DISCUSSION

E-cigarette marketing exposure was associated with sole-cannabis vaping and dual-vaping, not sole-nicotine vaping among U.S. adults. Such associations were mainly driven by young adults aged 18-24 and 25-34 years. Greater restrictions on tobacco marketing may have reduced the influence of e-cigarette marketing on nicotine vaping, while gaps in marketing restrictions for cannabis may contribute to e-cigarette marketing influence on cannabis vaping.

Associations of e-cigarette advertising exposure with curiosity and susceptibility among U.S. adolescents: National Youth Tobacco Surveys, 2014-2020

INTRODUCTION

Despite an evolving e-cigarette environment, few studies have looked at adolescent exposure to e-cigarette advertising over time and its associations with curiosity about and susceptibility to using e-cigarettes. We examined e-cigarette advertising exposure and its associations with curiosity and susceptibility across multiple years among adolescents who have never used e-cigarettes.

METHODS

We obtained data from the National Youth Tobacco Surveys (NYTSs), 2014-2020 (N = 97,496). The NYTS identified e-cigarette advertising exposure from four channels: Internet, newspapers and magazines, convenience stores, and TV. Logistic regressions explored e-cigarette advertising exposure over time and the associations between exposure from the four channels and both curiosity and susceptibility to using e-cigarettes.

RESULTS

Youth exposure to e-cigarette advertising on the Internet and in convenience stores formed an increase-decrease-increase pattern from 2014 to 2020, whereas exposure in newspapers and magazines and on TV generally decreased over this period. Exposure on the Internet and in convenience stores was consistently associated with curiosity and susceptibility; but exposure in newspapers and magazines and on TV was sporadically associated with the outcomes.

CONCLUSIONS

Despite a changing e-cigarette marketplace, youth were consistently exposed to e-cigarette advertising, especially on the Internet and in convenience stores. This pattern is worrisome, as it may increase youth curiosity and susceptibility to using e-cigarettes. Comprehensive tobacco prevention efforts to prevent e-cigarette use in adolescents should continue to restrict e-cigarette advertising and marketing, thereby reducing exposure and discouraging e-cigarette use. Regular efforts should also be made to educate adolescents about the risks of using e-cigarettes to counteract the impact of high e-cigarette advertising exposure.

Content Analysis of E-mail Marketing Communications Among Online E-cigarette Retailers

INTRODUCTION

Online e-cigarette retailers use e-mail communications to promote products directly to consumers, which may facilitate e-cigarette use. Little is known about the content of these e-mails. As such, this study collected e-mails from online e-cigarette retailers in California to conduct a content analysis.

AIMS AND METHODS

This study included 13 online e-cigarette retailers in California using Yelp. To be included in the study, e-cigarette retailers needed a live website, physical retail location (ie, vape shop), and e-cigarettes available for purchase online. The research team entered each website and signed up (if possible) for an e-mail newsletter. Data were collected from the Gmail Application Programming Interface over a 1-year study period (November 1, 2021-November 1, 2022). Members of the research team coded e-mails for the presence of e-cigarettes, other products, flavors, marketing categories, and promotional activities, among other variables.

RESULTS

Seven hundred and forty-nine promotional e-mails (2.1 avg/day) were received over the 1-year study period. Second-generation e-cigarettes (n = 581, 77.6%) were the most observed product in e-mails followed by disposable e-cigarettes (n = 391, 52.2%). The most common flavor profile was fruit or sweet or liquor (n = 424, 56.6%). E-mails included links to social media pages (n = 366, 48.9%). Online coupons were found in 53.1% (n = 398) of the e-mails. Age warnings were displayed in 8.0% (n = 60) of the e-mails.

CONCLUSIONS

E-cigarette retailers' e-mails promoted new products, flavors, and contained promotional discounts. Future research should examine the impact of exposure to such e-mails on e-cigarette-related attitudes and behaviors.

IMPLICATIONS

Findings from this study may help inform prevention programs and interventions focused on increasing tobacco-related digital media literacy (ie, evaluate tobacco advertising messages on digital media) among gender and ethnic minorities. Future research should examine if exposure to e-mail marketing is causally linked with e-cigarette use among gender and ethnic minorities.

Youth attention, perceptions, and appeal in response to e-cigarette advertising features: A focus group study

Background

E-cigarette marketing exposure may influence vaping-related outcomes among youth, but less is known on which specific advertising features impact youth attention, perceptions, and appeal. This study qualitatively examines responses to different e-cigarette advertising features among e-cigarette-naïve youth.

Methods

We conducted four online focus groups in 2021 with a national U.S. sample of 13-17 year olds (n = 25) who had never used e-cigarettes. Participants viewed and discussed their reactions to different e-cigarette advertisements varying in the inclusion of ad features, including color, models in imagery, text claims targeting smokers, and the nicotine warning label.

Results

Participants were attracted to ads with bright colors, particularly when contrasted against a dark background. Ads featuring models attracted attention and reduced perceptions that the product is harmful. Comments indicated mixed reactions to smoker-targeted text claims. On one hand, participants perceived ads with text that specified "for smokers" as targeting older adults. On the other hand, text referring to "switching" from cigarettes to e-cigarettes led to some perceptions that the product is healthy, and certain text that implicitly referred to smoking (e.g., "no odor") had the potential to appeal to youth who wanted to use e-cigarettes discreetly. The level of attention paid to warnings depended on warning size and the color contrast between the warning and the rest of the ad.

Conclusions

Findings suggest specific e-cigarette ad features play an important role in attracting youth attention and influencing perceptions. More research is needed on the potential public health benefits versus unintended consequences of smoker-targeted text claims.

Associations Between Noticing E-Cigarette Advertising Features and E-Cigarette Appeal and Switching Interest Among Young Adult Dual Users

BACKGROUND

E-cigarette advertising, which often includes various features, may prompt e-cigarette use and product switching. This study examined the associations between noticing e-cigarette ad features and perceived product appeal and interest in completely switching from cigarettes to advertised e-cigarettes among young adult dual users of both products.

METHODS

We analyzed data from an online heatmap experiment among young adult dual users defined as established cigarette smokers who currently used e-cigarettes (ages 18-34 years; n = 1,821). Participants viewed 12 e-cigarette ads, clicked on ad features (e.g., fruit flavors, nicotine warnings, price promotions, smoker-targeted claims) that attracted their attention (defined as "noticing"), and answered questions about e-cigarette product appeal and interest in completely switching from cigarettes to the e-cigarettes shown. We examined within-person associations between noticing specific ad features and outcomes, controlling for demographic and tobacco use-related characteristics.

RESULTS

Noticing fruit flavors (AOR = 1.67 and 1.28) and fruit images (AOR = 1.53 and 1.21) was positively associated with having any e-cigarette product appeal and switching interest. Noticing price promotions (AOR = 1.23) was positively associated with product appeal. In contrast, noticing nicotine warnings (AOR = 0.74 and 0.86), smoker-targeted claims (AOR = 0.78 and 0.89), and tobacco flavors (AOR = 0.92 and 0.90) was negatively associated with product appeal and switching interest.

CONCLUSIONS

Noticing certain e-cigarette ad features (e.g., fruit flavors and nicotine warnings) may be associated with product appeal and/or switching interest among young adult dual users. More research is needed to assess the influence of e-cigarette ad features that promote product switching interests among cigarette smokers while discourage interests among tobacco-naïve individuals.

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.

Using Eye tracking to Examine Young Adults' Visual Attention to E-cigarette Advertising Features and Associated Positive E-cigarette Perceptions

BACKGROUND

Little is known about the influence of e-cigarette marketing features on the antecedents of e-cigarette use.

PURPOSE

Using an eye-tracking experiment, we examined visual attention to common features in e-cigarette ads and its associations with positive e-cigarette perceptions among young adults.

METHODS

Young adults (ages 18-29) who smoke cigarettes (n = 40) or do not use tobacco (n = 71) viewed 30 e-cigarette ads on a computer screen. Eye-tracking technology measured dwell time (fixation duration) and entry time (time to first fixation) for 14 pre-defined ad features. Participants then completed a survey about perceptions of e-cigarettes shown in the ads. We used regression models to examine the associations between ad features and standardized attention metrics among all participants and by tobacco-use status and person-aggregated standardized attention for each ad feature and positive e-cigarette perceptions.

RESULTS

Dwell time was the longest for smoker-targeted claims, positive experience claims, and price promotions. Entry time was the shortest for multiple flavor descriptions, nicotine warnings, and people. Those who do not use tobacco had a longer dwell time for minor sales restrictions and longer entry time for purchasing information than those who smoke. Longer dwell time for multiple flavor descriptions was associated with e-cigarette appeal. A shorter entry time for fruit flavor description was associated with positive e-cigarette-use expectancies.

CONCLUSIONS

Young adults allocated attention differently to various e-cigarette ad features, and such viewing patterns were largely similar by tobacco-use statuses. Multiple or fruit flavors may be the features that contribute to the positive influence of e-cigarette marketing among young adults.

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.

Environmental influences on E-cigarette use among young people: A systematic review

E-cigarettes are a popular mode of delivery for nicotine, tobacco and cannabis. The prevalence of vaping among youth is increasing and this review aims to identify features of the neighbourhood environment, e.g., retailers, advertisements, and policies, that are associated with youth vaping. We included 48 studies. Of these, approximately 40% and 60% reported that presence of e-cigarette retailers, and advertisements, was associated with statistically higher odds of e-cigarette use in youth, respectively. Approximately 30% of studies reported that policies affecting e-cigarette availability were associated with statistically lower odds of vaping. Identifying these influential features of the neighbourhood environment will help formulate appropriate policies to reduce e-cigarette use among youth.

Vaping in a heavily regulated setting: cross-sectional survey of e-cigarette use, perceptions and social media exposure

BACKGROUND

Singapore has completely banned e-cigarettes and the government's cautious stance against vaping has been consistent. Despite this, vaping appears to have gained popularity in Singapore, especially among younger people. With the heavy marketing of vaping products on social media, it is possible that such marketing, due to its cross-border nature, is reaching younger Singaporeans and driving changes in vaping-related perceptions or behaviours. This study examines their exposure to vaping-related content on social media, and whether such exposure is associated with more positive perceptions of vaping or e-cigarette ever use.

METHODS

Analysis of cross-sectional survey data of 550 adult (age 21-40 years) Singaporeans recruited via convenience methods in May 2022, using descriptive statistics, bivariate analyses, and multiple linear and logistic regression models.

RESULTS

16.9% of participants reported they had ever used e-cigarettes. 18.5% of those who used social media recalled seeing vaping-related content on a social media platform in the past 6 months, mostly from influencers or friends, and on Instagram, Facebook, TikTok and/or YouTube. Reporting exposure to such content was not associated with e-cigarette ever use. It was associated with having a more positive overall perception of vaping (β=1.47; 95% CI: 0.17 to 2.78), although no significant difference was observed when examining only health-related perceptions.

CONCLUSION

Even in a heavily regulated environment such as Singapore's, people appear to be exposed to vaping-related content on social media platforms and this exposure is, in turn, associated with more positive perceptions of vaping, but not e-cigarette ever use.

Exploring the Influence of E-cigarette Ad Features on Perceived Product Appeal and Use Interest Among Young Adults of Varying Tobacco-Use Behaviors

INTRODUCTION

Exposure to certain features in commercial e-cigarette ads may influence e-cigarette use perceptions. This study explored the reactions toward common features in e-cigarette ads among young adults of various tobacco-use behaviors.

AIMS AND METHODS

We used data from in-depth interviews with U.S. young adults (ages 18-29) who do not use tobacco (n = 26) and who currently smoke cigarettes (n = 26). Participants viewed 30 print e-cigarette ads that included multiple features (eg, fruit flavors, price promotions, smoker-targeted messages) before discussing their perceived influence of memorable ad features. We used reflective thematic analysis to analyze interview data.

RESULTS

Participants from both groups generally noticed fruit and multiple flavors displayed in the ads, which were seen as appealing and were reported to generate product-use interest because of bright colors, sensory appeal, and a variety of flavor options. Participants who smoke perceived price promotions and positive experience testimonials to be appealing, and some reported this generated use interest. Participants from both groups perceived smoker-targeted messages to be unconvincing, and reported this dampened ad and product appeal and use interest. Participants who do not use tobacco perceived nicotine warnings to be unappealing, resulting in reduced perceived appeal of other attractive features (eg, fruit flavors) appearing in the same ads.

CONCLUSIONS

Marketing features appearing in e-cigarette ads may be perceived by young adults of various tobacco-use behaviors in both similar and different ways. Communication and policy strategies that account for these differential perceptions towards various marketing features are needed to reduce the negative impact of e-cigarette marketing.

IMPLICATIONS

This study revealed evidence related to young adults' reactions to and perceived influence of commonly used marketing features (eg, fruit flavors, nicotine warnings, price promotions, smoker-targeted messages) in commercial e-cigarette ads. The results highlight the similar and differential perceived appeal and use interest of e-cigarette products promoted with various marketing features among young adults of different tobacco-use behaviors. The results have implications for informing the design of communication strategies and policies related to e-cigarette marketing aimed at promoting complete product switching among young adults who smoke while simultaneously deterring e-cigarette use interest among those who do not use tobacco.

Associations between e-cigarette marketing exposure and vaping nicotine and cannabis among U.S. adults, 2021

Importance

Vaping has become an increasingly common method for consuming nicotine and cannabis, a trend potentially influenced by e-cigarette marketing. However, little is known about the influence of e-cigarette marketing on cannabis vaping behaviors.

Objective

To examine the associations between e-cigarette marketing exposure and nicotine and cannabis vaping behaviors among adults.

Design Setting and Participants

This cross-sectional study included a U.S. nationally representative sample of adults (≥18 years) from the Wave 6 survey of the Population Assessment of Tobacco and Health (PATH) Study, conducted from March to November 2021.

Exposure

Past 30-day e-cigarette marketing exposure (overall and by ten marketing channels).

Main Outcomes and Measures

Past 30-day vaping behavior (sole- and dual-vaping of nicotine and cannabis) overall and stratified by age.

Results

The study included 30,516 respondents (48.0% male and 63.9% non-Hispanic White). Overall, 52.0% of respondents reported past 30-day e-cigarette marketing exposure, and 89.8%, 5.6%, 3.2%, and 1.4% reported no vaping, sole-nicotine vaping, sole-cannabis vaping, and dual-vaping, respectively. Multinominal logistic regression results show exposure to e-cigarette marketing was associated with increased odds of reporting sole-cannabis vaping versus no vaping (adjusted risk ratio [aRR], 1.31; 95% confidence interval [CI], 1.09-1.57) and dual-vaping versus no vaping (aRR, 1.26; 95% CI, 1.01-1.57). Stratification analysis found these associations among those aged 18-24 and 25-34 years but not older adults (≥35 years). Those exposed to e-cigarette marketing also had increased odds of reporting sole-cannabis vaping versus sole-nicotine vaping (aRR, 1.28; 95% CI, 1.04-1.58). Stratification analysis found this association only among those aged 18-24 years. E-cigarette marketing exposure via several channels (retail stores, billboards, events, newspapers/magazines) was associated with increased odds of reporting sole-cannabis vaping.

Conclusions and Relevance

E-cigarette marketing exposure was only associated with sole-cannabis vaping and dual-vaping, not sole-nicotine vaping among U.S. adults. Such associations were mainly driven by young adults aged 18-24 and 25-35 years and were found for multiple marketing channels. Greater restrictions on tobacco marketing may have reduced the influence of e-cigarette marketing on nicotine vaping, while gaps in such marketing restrictions for cannabis may contribute to continued influence of e-cigarette marketing on cannabis vaping.

Marketing claims, promotional strategies, and product information on Malaysian e-cigarette retailer websites-a content analysis

BACKGROUND

Marketing and sales of e-cigarettes are unregulated in Malaysia. We analyzed content displayed on e-cigarette retailer websites to identify marketing claims, promotional strategies, and product details in the year 2022.

METHODS

We analyzed 30 Malaysia-based retailer websites using a mixed methods approach. Data were extracted as the frequency of occurrences of marketing claims, presence of regulatory information, product types, and flavors of e-juice as per a predefined codebook based on published literature. We also extracted textual details published on the websites about marketing claims, and slogans.

RESULTS

Most retailer websites provided contact information and physical store addresses (83%) but only half had 'click through' age verification (57%) that seldom needed any identification proof for age (3%). Marketing claims were related to health (47%), smoking cessation (37%), and modernity/trend (37%) and none had health warnings. Promotional strategies were discounts (80%). starter kits (57%) and email subscriptions (53%). Product types displayed were rechargeable (97%) and disposable (87%) devices and e-liquids (90%) of an array of flavors (> 100). Nicotine presence, its concentration, and "nicotine is an addictive chemical" were displayed in 93%, 53%, and 23% of websites respectively.

CONCLUSION

Surveillance of content displayed online on e-cigarette retailer websites and regulation of online marketing and sales should be implemented by the Ministry of Health, Malaysia. Such measures are needed to prevent access to, and initiation of e-cigarette use among the youth and adults who do not smoke.

Changes in E-cigarette Use, Cigarette Smoking, and Dual-Use Among the Youth (13-15 Years) in 10 Countries (2013-2019)-Analyses of Global Youth Tobacco Surveys

INTRODUCTION

The increasing use of e-cigarettes among the youth is a public health problem that needs surveillance. We report changes in e-cigarette use, cigarette smoking, and "dual use" among youth in 10 countries.

AIMS AND METHODS

Global Youth Tobacco Survey (GYTS)s from Georgia, Iraq, Italy, Latvia, Montenegro, Paraguay, Peru, Qatar, Romania, and San Marino were analyzed. Changes in prevalence of "awareness of e-cigarettes," "ever use" (even tried a few puffs) and "current use" (during last 30 days) of e-cigarettes and cigarette smoking, and "dual use" (both e-cigarette and cigarette smoking) between baseline (2013 and 2014) and most recent (2017-2019) surveys were estimated.

RESULTS

"Awareness of e-cigarettes" and "ever e-cigarette use" significantly increased (p < .001). "Ever e-cigarette use" was highest in Italy, 93% (95% CI 90.9, 94.4). "Current e-cigarette use" significantly (p < .05) increased by > 50% in most countries. During the most recent surveys, "current e-cigarette" use was > 10% in five countries Italy (18.3%) and Latvia (18.5%) being the highest. Cigarette smoking significantly declined in Italy, Latvia, Peru, and San Marino (p < .05) but remains unchanged in other countries. "Dual use" (both electronic and conventional cigarettes) significantly increased in all countries (p < .001). During the most recent surveys "dual use" was highest in Italy (10%, 95% CI 8.1, 12.2) and Latvia (8.6%, 95% CI 7.2, 10.2). Youth aged 14 and ≥15 years the smokers, were more likely to be e-cigarette users.

CONCLUSIONS

Awareness and use of e-cigarettes and "dual use" among youth have increased. Closer monitoring of tobacco use among youths and comprehensive tobacco control policies inclusive of e-cigarettes are needed.

IMPLICATIONS

Secondary data analyses of serial GYTSs in 10 countries showed that both awareness of e-cigarette and e-cigarette use has increased among school-going youth aged 13-15 years. A concurrent increase in "dual use" of e-cigarettes and cigarette smoking during the last 30 days in all 10 countries indicates continued cigarette smoking in the absence of e-cigarettes because of the common risk construct of tobacco product use. Results call for continued surveillance of both e-cigarettes and cigarette smoking among school-going youth. Comprehensive tobacco control measures inclusive of e-cigarettes should be implemented to reduce tobacco use among the youth.

Noticing people, discounts and non-tobacco flavours in e-cigarette ads may increase e-cigarette product appeal among non-tobacco-using young adults

INTRODUCTION

Young adults new to tobacco (including e-cigarettes) are at an increased risk of e-cigarette use after e-cigarette exposure. This study examined the association between noticing e-cigarette advertising features and perceived product appeal among non-tobacco-using young adults.

METHODS

A sample of non-tobacco-using young adults (ages 18-29 years; n=1993) completed an online survey in 2021. We content analysed visible features from 12 e-cigarette ads that represented commonly used e-cigarette brands. Participants viewed the ads and clicked on the areas of the ads that drew their attention. Participants reported e-cigarette product appeal for each ad, including ad liking, product curiosity and use interest. We used generalised estimating equations to examine within-person associations between noticing specific ad features and reporting each and any type of product appeal, adjusting for noticing other features and participant characteristics.

RESULTS

Noticing people, discounts, non-tobacco (menthol and mint/fruit) flavours, positive experience claims or product images was positively associated with having any e-cigarette product appeal. Noticing discounts or mint/fruit flavours was also positively associated with e-cigarette use interest. In contrast, noticing nicotine warnings or smoking cessation claims was negatively associated with ad liking and product curiosity.

CONCLUSIONS

Attention to several e-cigarette ad features (eg, people, discounts, non-tobacco flavours) was associated with increased e-cigarette product appeal, whereas attention to nicotine warnings and smoking cessation claims was associated with reduced appeal among non-tobacco-using young adults. Restricting appeal-promoting features while strengthening the effects of nicotine warnings and smoker-targeted claims in e-cigarette ads may potentially reduce e-cigarettes' overall appeal among this priority population.

Examining indirect effects of advertising exposure on young adults' cannabis and nicotine vaping

OBJECTIVE

To examine longitudinal associations between exposure to two types of advertisements (medical/recreational cannabis and e-cigarette retailers [vape shops]) and young adults' cannabis and nicotine vaping behavior. Positive and negative expectancies for cannabis and vaping nicotine were examined as mediators of these associations.

METHOD

Secondary analysis of observational data from a longitudinal cohort of young adults recruited from Southern California (Wave 13: N = 2,411, 56% female, Mage = 23.6). Participants completed web-based surveys annually, reporting on advertising exposure in 2018, expectancies in 2019, and cannabis and nicotine vaping in 2020. Two path models were specified: (a) of past-month cannabis vaping only, nicotine vaping only, and co-use (vs. no vaping) and (b) of single product vaping (vs. co-use). Path analyses modeled direct and indirect associations between variables.

RESULTS

Controlling for past-month cannabis and nicotine use and other covariates, there were no significant direct associations of advertising exposure with cannabis and/or nicotine vaping. However, the association between cannabis advertising exposure and vaping (cannabis only) was significantly mediated by positive cannabis expectancies (β = 0.02, SE = 0.01, p = .03). Among those who vaped cannabis and/or nicotine in the past month at Wave 13, expectancies did not significantly mediate associations between advertising exposure and single product use (vs. co-use).

CONCLUSIONS

Although exposure to cannabis advertisements may not be directly associated with young adults' cannabis vaping 2 years later, the effects of advertising exposure may be exerted indirectly by increasing positive beliefs about cannabis. Implications for public health policy are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Why and how should children be protected from the deluge of vaping related media and marketing overexposure?

E-cigarettes are products delivering nicotine via inhalation and are devised to mimic tobacco smoking. While they were initially introduced as a device putatively to aid with smoking cessation, their use is now far broader than that. Use by children is significantly increasing. There is growing evidence of the potential harms of vaping. E-liquids used for e-cigarettes contain a wide range of harmful substances, and the clinical consequences of this are now being increasingly demonstrated, such as the rise in cases of e-cigarette- or vaping-associated lung injury. In addition, early use may result in long-term nicotine addiction. Vaping companies utilise marketing methods that distinctly target young people, and weak legislation in the UK allows them free rein to expose children to vaping. In this review we demonstrate why children must be protected from vaping. We must have stringent legislation to prevent easy access to e-cigarettes, including banning the convenience and affordability disposable vapes provide, and prevent marketing that does not warn about the potential health effects. The Australia approach of prescription or pharmacy only access for smoking cessation should be considered to limit exposure of children and minimise use by nonsmokers.

Brief report on IQOS point-of-sale marketing, promotion and pricing in IQOS retail partner stores in Atlanta, Georgia, USA

OBJECTIVES

Philip Morris has a history of aggressive marketing tactics in its global pursuit of IQOS sales, which extant literature suggests may appeal to non-smokers and young adults. This study was the first to examine point-of-sale (POS) marketing and pricing of IQOS after it entered the US market in October 2019.

METHODS

Trained field staff assessed 75 retail partner stores selling IQOS/HeatSticks in the Atlanta area in February-November 2020 using an IQOS-tailored, standardised assessment tool. The tool assessed store characteristics, product availability and accessibility, marketing and promotions and pricing for each store.

RESULTS

All stores assessed sold HeatSticks in at least one of the three flavours (tobacco, smooth menthol, fresh menthol), but did not sell the IQOS device. IQOS/HeatSticks marketing was present inside 98.5% and outside 17.3% of stores assessed. Marketing for other tobacco products was present inside 98.5% and outside 32% of stores. The average price per HeatSticks pack was US$6.40 compared with US$6.08 for Marlboro Red cigarettes.

CONCLUSION

Our study revealed a considerable amount of POS marketing and promotion for IQOS/HeatSticks at retail partner locations, visible to all retail consumers, including youth and non-smokers. This study was the first to examine IQOS POS marketing and promotion in the US context and findings add to the extant literature on IQOS global marketing strategies. As additional novel tobacco/nicotine products continue to enter the market, targeted monitoring of the POS marketing and promotion for these new products is warranted.

Marketing claims on the websites of leading e-cigarette brands in England

INTRODUCTION

Exposure to electronic cigarette (EC) marketing is associated with EC use, particularly among youth. In England, the Tobacco and Related Products Regulations and Committee of Advertising Practice (CAP) regulate EC marketing to reduce appeal to youth; however, there are little published data on EC marketing claims used online. This study therefore provides an overview of marketing claims present on the websites of EC brands popular in England.

METHODS

From January to February 2022, a content analysis of 10 of England's most popular EC brand websites was conducted, including violation of CAP codes.

RESULTS

Of the 10 websites, all presented ECs as an alternative to smoking, 8 as a smoking cessation aid and 6 as less harmful than smoking. Four websites presented ECs as risk-free. All mentioned product quality, modernity, convenience, sensory experiences and vendor promotions. Nine featured claims about flavours, colours, customisability and nicotine salts. Seven featured claims concerning social benefits, personal identity, sustainability, secondhand smoke and nicotine strength. Six featured claims about fire safety. Some claimed ECs are cheaper than tobacco (n=5), cited health professionals (n=4) or featured collaborations with brands/icons (n=4). All were assessed by the research team to violate one or more CAP code(s) by featuring medicinal claims (n=8), contents which may appeal to non-smokers (n=7), associations with youth culture (n=6), depictions of youth using ECs (n=6) or media targeting youth (n=5).

CONCLUSION

Among 10 top EC brand websites in England, marketing elements that might appeal to youth were commonly identified and CAP code compliance was low.

Presence of flavoured electronic nicotine delivery system (ENDS) products in US ENDS advertisements, 2015-2020: a content analysis

OBJECTIVES

Electronic nicotine delivery systems (ENDS) products come in a variety of flavours (eg, fruit, dessert, menthol). Tobacco advertising has historically used flavours as an advertising tactic, but little is known about flavour type and prevalence in ENDS advertisements. We assess the presence of flavoured ENDS in ads over time, by media outlet (eg, magazines, online) and brand.

METHODS

We acquired ENDS ads (N=4546) that first ran between 2015-2017 (n=1685; study 1) and 2018-2020 (n=2861; study 2) in outlets including opt-in emails, direct-to-consumer mail (study 1 only), video (TV and online), radio (study 2 only), static online/mobile (ie, ads without video or moving graphics), social media, outdoor (eg, billboards; study 2 only) and consumer magazines. We coded for presence of flavoured ENDS products and flavour type (eg, fruit, tobacco, menthol) and merged this information with metadata on ad year, outlet and manufacturer/retailer brand.

RESULTS

Overall, nearly half (45.5%; n=2067) of ads in our sample featured a flavoured product. Tobacco (59.1%; n=1221), menthol (42.9%; n=887) and fruit (38.6%; n=797) were the most advertised flavours. Over time, the proportion of ads containing tobacco-flavoured and menthol-flavoured ENDS generally decreased before menthol rebounded in 2020. The proportion of ads containing fruit, mint and dessert flavours generally increased over time, with a substantive drop in 2020. We found notable differences in flavoured ENDS advertising by outlet and brand.

CONCLUSIONS

The overall presence of flavoured ENDS in our sample of ads remained relatively consistent, with tobacco flavour decreasing over time and some non-tobacco flavours increasing over time until 2020 when the presence decreased.

The availability and distribution of vaping retailers across Ontario neighbourhoods, 2016-2019

OBJECTIVES

To characterize the distribution of vaping retailers and examine the association between neighbourhood income and vaping retailer availability in Ontario prior to and after regulatory changes to the vaping market in 2018.

METHODS

We quantified vaping access by number of vaping retailers for 19,964 dissemination areas (DAs) in Ontario and percentage of schools near a vaping retailer. We used mixed-effects regression models to examine the associations between vaping access and neighbourhood income in 2018 and 2019.

RESULTS

Between 2016 and 2019, the number of vaping retailers in Ontario increased by 22.6% (5999 to 7355), despite a mild drop from 2016 to 2018. In 2019, 59.7% of urban neighbourhoods had one or more vaping retailers within 1000 m of their geographic centre, and 79.4% of elementary, 82.8% of secondary, and 84.2% of post-secondary schools had at least one within 1000 m. Neighbourhood income was associated with access to vaping retailers, with a greater number in low-income regions. In 2019, neighbourhoods in the lowest income quintile had over twice the number of vaping retailers per capita within 1000 m compared to the highest income quintile (adjusted incidence rate ratio 2.40; 95% CI 2.24-2.58). Increases over time in access to vaping retailers did not differ by geographic region, neighbourhood income quintile, or school type.

CONCLUSION

We observed a substantial increase in access to vaping retailers in Ontario including proximity to elementary and secondary schools following the 2018 provincial marketing regulations and federal nicotine regulations. Access to vaping was greatest in low-income neighbourhoods and may contribute to established inequities in vaping-related adverse events.

Young Adult Responses to Peer Crowd-Based Targeting in E-cigarette Advertisements: An Experimental Study

AIMS

To examine the effects of psychographically targeted e-cigarette advertisements on young adults.

METHODS

A total of 2100 young adults (18-29 years old) representing five peer crowds (groups with shared values, interests, and lifestyle: Mainstream, Young Professional, Hip Hop, Hipster, and Partier) were recruited from a nationwide opt-in online panel. Participants were randomly assigned to view e-cigarette advertisements featuring characters that either did or did not match their own peer crowd affiliation and evaluated advertising effectiveness using Likert-type and semantic differential scales. Participants also reported their attitudes toward using e-cigarettes.

RESULTS

No significant overall effect of peer crowd matching was observed. However, significant two-way interaction effects emerged where matching advertisements yielded higher evaluations than mismatching advertisements among those who currently do not use tobacco and nicotine products and among Mainstream participants. Advertisements featuring Mainstream characters were in general rated more highly than other advertisements. Additional analyses found significant effects of peer crowd matching among those who viewed advertisements featuring non-Mainstream characters.

CONCLUSIONS

Peer crowd-based targeting can increase the effectiveness of e-cigarette advertisements which may impact initiation among current nonusers, requiring stricter marketing regulations. More research is needed to determine if anti-tobacco messaging tailored by peer crowds may effectively counteract targeted e-cigarette marketing.

IMPLICATIONS

E-cigarette advertisements often use psychographic targeting strategies, using lifestyles, attitudes, and values. Low-risk young adults (eg, those who currently do not use tobacco and nicotine products) are susceptible to psychographically targeted e-cigarette advertisements. This may result in the initiation of e-cigarette use among young adults who would otherwise be less likely to use tobacco and nicotine products. Stricter marketing regulations for emerging tobacco and nicotine products are required to reduce marketing exposure.

A Machine Learning Approach Reveals Distinct Predictors of Vaping Dependence for Adolescent Daily and Non-Daily Vapers in the COVID-19 Era

Since 2016, there has been a substantial rise in e-cigarette (vaping) dependence among young people. In this prospective cohort study, we aimed to identify the different predictors of vaping dependence over 3 months among adolescents who were baseline daily and non-daily vapers. We recruited ever-vaping Canadian residents aged 16-25 years on social media platforms and asked them to complete a baseline survey in November 2020. A validated vaping dependence score (0-23) summing up their responses to nine questions was calculated at the 3-month follow-up survey. Separate lasso regression models were developed to identify predictors of higher 3-month vaping dependence score among baseline daily and non-daily vapers. Of the 1172 participants, 643 (54.9%) were daily vapers with a mean age of 19.6 ± 2.6 years and 76.4% (n = 895) of them being female. The two models achieved adequate predictive performance. Place of last vape purchase, number of days a pod lasts, and the frequency of nicotine-containing vaping were the most important predictors for dependence among daily vapers, while race, sexual orientation and reporting treatment for heart disease were the most important predictors in non-daily vapers. These findings have implications for vaping control policies that target adolescents at different stages of vape use.

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.

Longitudinal transitions in tobacco use in youth and young adults: A latent transition analysis of the population assessment of tobacco and health study from Wave 1 to 5

BACKGROUND

Tobacco use by youth and young adults can lead to significant long-term health problems. We aim to understand transitions in tobacco use patterns among these groups and the factors that affect transition patterns.

METHODS

Using the five waves of data from the nationally representative Population Assessment of Tobacco and Health (PATH) Study (2013-2019), we conducted latent class analysis and latent transition analysis to understand tobacco use classes and the longitudinal transitions between classes. We also adjusted for covariates, including demographics, individual behaviors, household environment, and psychosocial factors, to capture their effects on class transition probabilities.

RESULTS

Three tobacco use behaviors were identified: non-current user (C1), moderate e-cigarette user (C2), and poly-tobacco user (C3). At baseline (Wave 1), 94.4% of participants were classified as C1, 3.2% as C2, and 2.4% as C3, and the distribution shifted towards C2 and C3 over time. Progression to the next class represented the most common transitions (14.1% C2 to C3, 10.7% C1 to C2), while the direct progression from C1 to C3 was rare (0.6%). Being male, White, adult, living in smoking-allowed households, past-year alcohol use, drug use, internalizing problems, and social media follower of tobacco brands were associated with a faster progression to poly-tobacco use.

CONCLUSIONS

The transition patterns implied that e-cigarette use might be an intermediate progression from non-current use into poly-tobacco use. Individual behaviors, household environment, and psychosocial factors are associated with elevated risks of progression. The findings may inform tobacco prevention and cessation policies among youth and young adults.

Price promotion receipt and use progression of any tobacco, cigarettes, e-cigarettes and cigars among US youth between 2016 and 2018

BACKGROUND

Tobacco price promotions may prompt tobacco trials among youth. We assessed whether receiving price promotions for any tobacco, cigarettes, e-cigarettes and cigars was associated with product use progression.

METHODS

The analysis included a nationally representative sample of youth never tobacco users (aged 12-16; n=9405) from wave 4 (2016-2018) of the Population Assessment of Tobacco and Health Study. We assessed past-year receipt of price promotions and use progression (initiation, current use and ever regular use) for any tobacco, cigarettes, e-cigarettes and cigars 1 year later at wave 4.5 (2017-2018). Multivariable logistic regressions were used to examine the associations between receiving price promotions and use progression by product type, controlling for covariates.

RESULTS

At wave 4.5, 9.4% of youth initiated any tobacco (1.8%, 7.8% and 0.9% for cigarettes, e-cigarettes and cigars), and 5.4% received any price promotions (3.8%, 3.1% and 0.9% for cigarettes, e-cigarettes and cigars). Receiving any tobacco price promotions was associated with any tobacco initiation (adjusted OR (AOR)=1.77; 95% CI 1.30 to 2.41), current use (AOR=1.54; 95% CI 1.06 to 2.23) and ever regular use (AOR=1.76; 95% CI 1.04 to 3.10). Receiving e-cigarette price promotions was associated with e-cigarette initiation (AOR=1.78; 95% CI 1.18 to 2.26), current use (AOR=1.88; 95% CI 1.17 to 3.02) and ever regular use (AOR=2.10; 95% CI 1.02 to 4.40). The associations specific to cigarettes and cigars were only found for product initiation.

DISCUSSION

Receiving price promotions for any tobacco and e-cigarettes was respectively associated with the use progression of any tobacco and e-cigarettes. Continuous monitoring of tobacco marketing activities is needed to identify youth-appealing price promotion tactics.

Association between Sexual Violence Victimization and Electronic Vaping Product Use among Adolescents: Findings from a Population-based Study

BACKGROUND

Although studies have investigated the association between sexual violence (SV) victimization and substance use, few studies have examined the association between SV victimization and electronic vaping product (EVP) use among adolescents in the United States. The objective of this study was to examine the cross-sectional association between SV victimization and EVP use among adolescents.

METHODS

Data were pooled from the 2017 and 2019 Youth Risk Behavior Survey. An analytic sample of 28,135 adolescents (51.2% female) was analyzed using binary logistic regression. The outcome variable investigated was EVP use, and the main explanatory variable was SV victimization.

RESULTS

Of the 28,135 adolescents, the prevalence of past 30-day EVP use and SV victimization was 22.7% and 10.8%, respectively. Controlling for other factors, adolescents who experienced SV had 1.52 times higher odds of being EVP users when compared to their counterparts who did not experience SV (AOR = 1.52, p < .001, 95% CI = 1.27-1.82). Other factors associated with EVP use included cyberbullying victimization, symptoms of depression, and current use of cigarettes, alcohol, and marijuana.

CONCLUSIONS

Experiencing SV was associated with EVP use. Future studies that employ longitudinal designs may offer more insight into the mechanisms underlying the association between SV victimization and EVP use. In addition, school-based interventions that focus on sexual violence prevention and reducing substance use among adolescents are warranted.

A Comparative Analysis of E-Cigarette and Cigarette Posts on Instagram

E-cigarette use has grown rapidly over the past decade and become a threat to public health. Marketing-especially through social media-has contributed significantly to this growth, which suggests that regulating content in social media will be critical in supporting efforts to reverse this trend. A content analysis was performed to compare 254 e-cigarette posts on Instagram with 228 cigarette posts on the same platform. The majority of e-cigarette posts were from e-cigarette companies (40.9%) and industry people (18.5%), whereas the majority of cigarette posts were from laypeople (76.8%). More e-cigarette posts than cigarette posts appeared to have a marketing intent (56.3% vs. 1.3%), and brand representation in photographs/videos was more frequent in the e-cigarette posts than in the cigarette posts (63.0% vs. 15.8%). Further, compared with the e-cigarette posts, the cigarette posts were more likely to portray daily life (73.2% vs. 41.3%) and humans (80.3% vs. 43.7%) in the photograph/video. The cigarette posts also portrayed smoking much more often than the e-cigarette posts portrayed vaping (67.1% vs. 21.3%). The study findings broaden the field's understanding of cigarette and e-cigarette content on Instagram and social media, and have implications for monitoring and regulating content for e-cigarettes and cigarettes.

How the Other Half Sees It: E-cigarette Advertising Exposure and Subsequent E-cigarette Use Among U.S. Young Adult Cigarette Smokers

INTRODUCTION

E-cigarette advertising may benefit young adult cigarette smokers in transitioning to using e-cigarettes. We assessed whether e-cigarette advertising exposure was associated with subsequent e-cigarette use among young adult cigarette smokers.

AIMS AND METHODS

Data were from Waves 4 (2016-2018) and 5 (2018-2019) of the nationally representative Population Assessment of Tobacco and Health (PATH) study adult survey. Respondents were young adult established cigarette smokers at Wave 4 (18-34 years; n = 3391) and a subsample of those who tried to quit smoking cigarettes completely in the past year at Wave 5 (n = 1235). Multivariable logistic regressions were used to examine the associations between e-cigarette advertising exposure (by channel of exposure) and subsequent past-year e-cigarette use in general and e-cigarette use to quit smoking cigarettes, controlling for covariates.

RESULTS

At Wave 5, 43.4% of smokers reported past-year use of e-cigarettes; and 14.8% of smokers who tried to completely quit smoking reported past-year use of e-cigarettes to quit. E-cigarette advertising exposure was associated with subsequent past-year e-cigarette use (adjusted odds ratio [AOR] = 1.53, p < .0001, 95% confidence interval [CI] = 1.27, 1.86) and past-year use to quit smoking cigarettes (AOR = 1.65, p < .01, 95% CI = 1.19, 2.29). Advertising exposure through brick-and-mortar stores or websites/social media was similarly associated with both e-cigarette use behaviors.

DISCUSSION

Exposure to e-cigarette advertising among U.S. young adult established cigarette smokers may be associated with subsequent e-cigarette use and use to quit smoking. More research is needed to understand the features of e-cigarette advertising (eg, discounts, flavors, smoker-targeted claims) that may shape perception and behavior related to e-cigarette use among young adult smokers.

IMPLICATIONS

Little is known about the associations between e-cigarette advertising exposure and e-cigarette use among young adult cigarette smokers who may benefit from switching to e-cigarettes. This study found that e-cigarette advertising exposure was positively associated with (1) subsequent e-cigarette use among U.S. young adult established cigarette smokers and (2) subsequent e-cigarette use to quit smoking cigarettes among those who tried to completely quit in the past year. These observed associations were driven by smokers who did not currently use e-cigarettes at baseline. E-cigarette advertising exposure through brick-and-mortar stores or websites/social media was also positively associated with subsequent e-cigarette use behaviors.

U.S. digital tobacco marketing and youth: A narrative review

We describe findings from peer-reviewed articles on digital tobacco marketing (DTM) using U.S. data related to youth, including research that examines use of age restrictions, DTM exposure and engagement, and associated tobacco use. We searched PubMed, EMBASE, Web of Science, and EBSCOhost in May 2019 and May 2020 for published English language peer-reviewed articles examining DTM that were published from January 2016 to May 2020. Inclusion coding occurred in three stages. The first search identified 519 articles; 167 were coded for inclusion. The second search identified 189 articles; 67 were coded for inclusion. Two coders then assessed whether the included articles mentioned youth (age 18 and younger) or age restrictions in the method and results sections of the full text. Ultimately, 47 articles were included in this review. A codebook was developed and tested through training. Each article was coded for age restrictions, youth exposure to DTM, youth engagement with DTM, and youth tobacco use associated with DTM exposure or engagement. The studies reviewed indicate that DTM on social media was infrequently age-restricted and the stringency of age restriction varied by tobacco product, site owner, and channel. Youth reported being exposed to DTM frequently via the Internet. While youth reported less frequently engaging with DTM compared to being exposed, engagement increased over time. DTM exposure and engagement were associated with tobacco product use. The studies reviewed document an association between DTM exposure and engagement and future tobacco use; thus, DTM may be contributing to the youth tobacco epidemic.

How Does Social Media Exposure and Engagement Influence College Students' Use of ENDS Products? A Cross-lagged Longitudinal Study

Electronic nicotine delivery systems (ENDS) products have been marketed heavily on social media throughout the past years, which exerts great influence on young adults' ENDS use. Despite scholars' pioneering efforts in investigating the influence of tobacco and nicotine products marketing on young adults' vaping behavior, scholarly attention has been paid primarily to passive exposure to rather than active engagement with the information on social media. In addition, the majority of existing research has been cross-sectional or focused on the unidirectional path from marketing information to behavior. To extend previous research in tobacco regulatory science on new media, we examined the bidirectional associations between self-reported exposure to and engagement with tobacco and nicotine products messaging on social media, and subsequent use of ENDS products one year later among a large, diverse sample of young adults. Results from cross-lagged panel analyses indicated that pro-tobacco/ENDS engagement and advertising exposure elevated risk whereas anti-tobacco/ENDS engagement decreased risk for the subsequent use of ENDS products one year later. On the other hand, the use of ENDS products positively predicted both pro- and anti-tobacco/ENDS engagement one year later. Findings provide empirical support for the reasoned action approach and the confirmation bias rooted in cognitive dissonance theory through rigorous longitudinal examination. Our findings not only point to the imperativeness of and offer guidance for regulating marketing information on social media, but also suggest social media as a promising platform to prevent young adults from initiating ENDS product use.

Effect of a hypothetical modified risk tobacco product claim on heated tobacco product use intention and perceptions in young adults

INTRODUCTION

Modified risk tobacco product (MRTP) claims for heated tobacco products (HTPs) that convey reduced exposure compared with conventional cigarettes may promote product initiation and transition among young people. We assessed the effects of a hypothetical MRTP claim for HTPs on young adults' intention and perceptions of using HTPs and whether these effects differed by their current cigarette and e-cigarette use.

METHODS

We embedded a randomised between-subjects experiment into a web-based survey administered among a cohort of 2354 Southern California young adults (aged 20-23) in 2020. Participants viewed depictions of HTPs with an MRTP claim (n=1190) or no claim (n=1164). HTP use intention and HTP-related harm and use perceptions relative to cigarettes and e-cigarettes were assessed.

RESULTS

Overall, participants who viewed versus did not view the claim did not differ in HTP use intention (28.5% vs 28.7%) but were more likely to perceive HTPs as less harmful than cigarettes (11.4% vs 7.0%; p<0.001). The experimental effect on HTP use intention did not differ among past 30-day cigarette smokers versus non-smokers (interaction adjusted OR (AOR)=0.78, 95% CI 0.36 to 1.76) but differed among past 30-day e-cigarette users versus non-users (interaction AOR=1.67, 95% CI 1.02 to 2.68).

DISCUSSION

The hypothetical MRTP claim may lower young adults' HTP harm perceptions compared with cigarettes but may not change HTP use intention overall or differentially for cigarette smokers. The larger effect on HTP use intention among e-cigarette users than non-users raises the question of whether MRTP claims may promote HTP use or HTP and e-cigarette dual use among young e-cigarette users.

Association between use of electronic vaping products and insufficient sleep among adolescents: Findings from the 2017 and 2019 YRBS

BACKGROUND AND OBJECTIVE

Although studies have investigated the association between cigarette smoking and sleep outcomes among adolescents in the United States, few studies have examined the association between electronic vaping products (EVPs) use and insufficient sleep among adolescents. The objective of this study was to investigate the cross-sectional association between the use of EVPs and insufficient sleep among adolescents.

METHODS

Data were pooled from the 2017 and 2019 Youth Risk Behavior Survey. An analytic sample of 28,135 adolescents (51.2% female) was analyzed using binary logistic regression. The dependent variable investigated was insufficient sleep, and the main independent variable was the use of EVPs.

RESULTS

Of the 28,135 adolescents, 22.6%, 19.2%, and 58.2% were current, former, and never users of EVPs, respectively. More than three in four adolescents (76.5%) did not obtain the recommended 8 h of sleep on an average school night. Controlling for demographic factors and other covariates, adolescents who currently used EVPs had 1.33 times higher odds of having insufficient sleep (AOR = 1.33, p < .001, 95% CI = 1.16-1.52), and adolescents who previously used EVPs had 1.29 times higher odds of having insufficient sleep (AOR = 1.29, p < .001, 95% CI = 1.15-1.44) when compared to adolescents who had never used EVPs. Adolescents were more likely to get insufficient sleep if they were older, non-Hispanic Black, had symptoms of depression, experienced suicidal ideation, engaged in excessive screen-time behaviors, or currently used alcohol. Physical activity had a protective effect on insufficient sleep.

CONCLUSION

This study found that EVPs use was associated with insufficient sleep among adolescents over and above demographic and other covariates. As EVP use increases among adolescents, it is important to consider the potential impact on multiple domains, including sleep. Future studies that employ longitudinal designs may offer additional insight into the mechanisms underlying the association between EVPs use and insufficient sleep.

Electronic cigarettes use and 'dual use' among the youth in 75 countries: estimates from Global Youth Tobacco Surveys (2014-2019)

We report the country-level prevalence of awareness about electronic cigarette use, and 'dual use' and its association with age, sex, country income, and e-cigarette regulatory status. We analyzed the most recent Global Youth Tobacco Surveys done on nationally representative samples of school-going youth aged 13-15 years in 75 countries/territories. The weighted prevalence of 'awareness' (heard about e-cigarettes), 'ever use' (even tried a few puffs), 'current use' (during the last 30 days), and 'dual use' (e-cigarette use and cigarette smoking during the last 30 days) were estimated. Awareness was > 80% in 13 countries mostly from Europe Poland being the highest at 95.8% (95% CI 94.8- 96.6). In seven countries, 30-50% of the youth had ever used an e-cigarette, Italy was the highest at 55.1% (95%CI 51-3,58.9). In 30 countries, current e-cigarette use was > 10%, the highest of 35.1% (95%CI 32.4-38.0) in Guam. Awareness and use were highest in the European region (74.6% and 34.5%) and HIC (83.6% and 39.4%). Youth from HIC (compared to lMIC) and countries having restrictive e-cigarette regulations (compared to NRP) had 2.4 times (aOR 2.2.4, 95% CI 2.2, 2.7) and 1.8 times (aOR 1.8, 95% CI 1.6, 2.0) higher odds of being current e-cigarette users respectively. Youth in countries with the most restrictive e-cigarette regulations (compared to NRP) had 0.6 times lower odds of being current e-cigarette users (aOR 0.6, 95% CI 0.6, 0.7). Awareness and e-cigarette use varied by sex, country income level, and region. Continued global surveillance of youth e-cigarette use is needed for the formulation of e-cigarette regulatory policy. Awareness and use of e-cigarettes were higher among boys, in countries in Europe and America regions, and among those with higher income and restrictive policies, whereas it was lower in countries having the most restrictive policies. Higher awareness is strongly correlated with a trial and current use of e-cigarettes. E-cigarette marketing should be restricted, and continued surveillance of e-cigarette use is needed. Most restrictive policies such as the ban on e-cigarettes appear to reduce e-cigarette use among the youth.

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.

Testing if attitudes mediate the association between advertising exposure and adolescent tobacco use

INTRODUCTION

A growing body of evidence indicates that exposure to tobacco advertising among adolescents increases the likelihood of subsequent tobacco use. It is important to understand the process by which this occurs, in order to appropriately target factors for intervention. The objective of this study was to test whether attitudes towards tobacco advertising mediates the impact of advertising exposure on tobacco use.

METHODS

From an ongoing prospective cohort study of male adolescents (aged 11-16 at baseline), we recruited a subset of tobacco users and non-users to participate in an additional ecological momentary assessment (EMA) project (N = 164). Adolescents completed smartphone-based surveys 2-3 times/day over a 10-day period with items assessing their exposures and attitudes towards tobacco-related advertising. If participants reported exposure to tobacco advertising, they were asked about their attitudes toward it (how much they enjoyed it, liked it, and found it appealing).

RESULTS

Adolescents who reported a greater amount of advertising exposure during the EMA period were more likely to report past-30-day tobacco use at their next cohort follow-up (6-12 months later). Moreover, the impact of advertising exposure on subsequent use was mediated by attitudes toward the tobacco advertisements, as reported during the EMA. This effect remained after controlling for baseline tobacco use.

CONCLUSIONS

By pairing EMA with long-term follow-up, we identified attitudes as a mediator between adolescent advertising exposure and subsequent tobacco use. Interventions to lessen adolescents' positive attitudes toward tobacco advertisements may help disrupt this impact.

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.

Association between E-Cigarette Advertising Exposure and Use of E-Cigarettes among a Cohort of U.S. Youth and Young Adults

Youth and young adult (YYA) use of e-cigarettes increased rapidly between 2010 and 2019 in the United States, during which exposure to e-cigarette advertising was also increased. We aimed to examine whether exposure to e-cigarette advertising among YYAs may lead to subsequent e-cigarette use. A cohort of 3886 YYAs ages 13-24 was recruited from two survey panels in 2018 and followed up until 2019. Survey data were collected online and by telephone. The primary outcome was past 30-day use of e-cigarettes at the follow-up survey. Among 2304 YYAs who retained at the follow-up survey and were not past 30-day e-cigarette users at baseline, both youth and young adults exposed to e-cigarette advertising at baseline had elevated odds of past 30-day e-cigarette use at follow-up (Youth adjusted odds ratio (aOR): 2.77, 95% CI: 1.23, 6.24; Young adults aOR: 2.34, 95% CI: 1.08, 5.11) compared with those not reporting baseline advertising exposure. The majority of YYAs reported exposure to e-cigarette advertising at baseline (Youth: 63.7%, 95% CI: 59.8, 67.4; Young adults: 58.3%, 95% CI: 53.6, 62.8). Our findings suggest that exposure to e-cigarette advertising was associated with an increase in subsequent past 30-day use of e-cigarettes among YYAs. Restricting advertising targeted at YYAs may reduce the likelihood of e-cigarette use among YYAs.

Anesthesiologists and the Other Pandemic: Tobacco Use

Tobacco use will kill a projected 1 billion people in the 21st century in one of the deadliest pandemics in history. Tobacco use disorder is a disease with a natural history, pathophysiology, and effective treatment options. Anesthesiologists can play a unique role in fighting this pandemic, providing both immediate (reduction in perioperative risk) and long-term (reduction in tobacco-related diseases) benefits to their patients who are its victims. Receiving surgery is one of the most powerful stimuli to quit tobacco. Tobacco treatments that combine counseling and pharmacotherapy (e.g., nicotine replacement therapy) can further increase quit rates and reduce risk of morbidity such as pulmonary and wound-related complications. The perioperative setting provides a great opportunity to implement multimodal perianesthesia tobacco treatment, which combines multiple evidence-based tactics to implement the four core components of consistent ascertainment and documentation of tobacco use, advice to quit, access to pharmacotherapy, and referral to counseling resources.

Trajectories of e-cigarette advertising exposure, e-cigarette use and cigarette smoking in a sample of young adults from Hawaii

AIM

To test whether intrapersonal growth in e-cigarette advertising exposure over time is associated with growth in e-cigarette use and/or cigarette smoking.

DESIGN

Longitudinal study using four waves of data were collected in 6-month intervals between 2018 and 2020.

SETTING AND PARTICIPANTS

Participants were 2327 young adults recruited from colleges in Hawaii, USA.

MEASUREMENTS

Data were collected on demographics, e-cigarette advertising exposure measured using the cued- recall method and recent (past 30-day) cigarette and e-cigarette use.

FINDINGS

The average trajectory for e-cigarette advertising exposure over time was significant and upward [M slope = 0.18 (0.14-0.22), P < 0.0001]. However, average trajectories for e-cigarette [M slope = -0.08 (-0.18 to 0.02), P = 0.09] and cigarette [M slope = -0.14 (-0.30 to 0.02), P = 0.07] use were not. There were significant differences in individual level trajectories across participants for advertising exposure [σ2  = 0.12 (0.10-0.14), P < 0.0001], e-cigarette use [σ2  = 0.22 (0.14-0.30), and cigarette smoking (σ2  = 0.17 [0.09-0.25], P < 0.0001). Individuals with an increasing rate of advertising exposure showed an increasing rate of e-cigarette use [B = 0.63 (0.36-0.90), P < 0.0001). Neither initial level of, nor rate of change in, advertising exposure was significantly associated with cigarette smoking growth factors (P > 0.05). Higher initial level of e-cigarette use was associated with higher initial level of cigarette smoking [B = 0.89 (0.69-1.09), P < 0.0001] but decreased rate of cigarette smoking over time [B = -0.12 (-0.20 to -0.04) P = 0.003]. Rate of change in e-cigarette use was not associated with the rate of change in cigarette smoking (P > 0.05).

CONCLUSIONS

Increased exposure to e-cigarette advertising appears to be associated with increased e-cigarette use but not with increased cigarette smoking. Higher initial level of e-cigarette use appears to be associated with higher initial level of cigarette smoking but may be associated with a decreasing rate of cigarette smoking over time.

Real-Time Context of Tobacco Marketing Exposure and Community Vulnerability-An Ecological Momentary Assessment Among Young Adults

BACKGROUND

Exposure to tobacco product marketing increases tobacco use among young adults, especially those from vulnerable communities (VCs).

PURPOSE

This study examined real-time tobacco marketing exposure among young adults from vulnerable and non-vulnerable communities using Ecological Momentary Assessment (EMA).

METHODS

This study used EMA data to assess context (e.g., location and activity) of tobacco marketing exposure using four text-messaging surveys per day over 2 weeks. Young adult non-current tobacco users living in Washington, D.C. (n = 146; ages 18-24) recorded 5,285 surveys, including 20 participants (13.2%) from VCs with high proportions of lower income and racial/ethnic minorities, and high smoking rates. Unadjusted and adjusted multilevel logistic regressions were used to assess the associations between exposure to any and flavored tobacco marketing, VC residence, and real-time context.

RESULTS

Fifty-nine participants (40.4%) reported at least one tobacco marketing exposure and recorded 94 exposure moments. In adjusted models, odds of exposure were higher among VC residents (AOR = 2.6, 95% CI = 1.2-5.4), in the presence of anyone using tobacco versus no use (AOR = 4.0, 95% CI = 2.4-6.7), at store/retail (AOR = 17.0, 95% CI = 6.4-44.8), or outside/in transit (AOR = 4.1, 95% CI = 2.1-7.8) versus at home. VC residence (AOR = 7.2, 95% CI = 2.3-22.2) was the strongest predictor of flavored tobacco marketing exposure among all covariates examined.

CONCLUSIONS

Young adults are predominantly exposed to tobacco marketing in their daily lives through retail advertisements. Young adults from VCs are at increased risks of seeing any tobacco and especially flavored tobacco marketing. Policies that curtail tobacco retailer density and advertisement displays may reduce overall and differential tobacco marketing exposure.

E-cigarette disparities: Who are the targets?

The tobacco industry has a long history of promoting health disparities especially through targeted marketing campaigns. The disparities perpetuated by e-cigarettes are just becoming apparent. This article will focus on disparities in e-cigarette usage within the following categories of youth: racial or ethnic groups, sexual and gender minoritized individuals, adolescents with asthma, teens with disabilities, and those coping with mental health stresses. Millions of youth are still using e-cigarettes, and e-cigarette use is disproportionately impacting White youth, youth who identify at lesbian, gay and transgender, and youth with disabilities. In addition, this article highlights the timeline of key tobacco regulations and recommended actions to curb the e-cigarette epidemic.

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.

Physical and Sociocultural Community-Level Influences on Cigar Smoking among Black Young Adults: An In-Depth Interview Investigation

Black young adults experience disparately high rates of cigar use and its health consequences. Little research has explored community-level influences on cigar smoking in this population, especially concerning product-specific influences and cigar smokers' perceptions. We conducted in-depth interviews with 40 Black young adult (ages 21-29) cigar smokers in the Washington, D.C. area and analyzed themes regarding physical and sociocultural community-level factors perceived to influence cigar use. Themes were further analyzed based on participants' predominant cigar products (cigarillos, large cigars, blunts). Participants reported easy access to affordable cigarillos, widespread cigarillo sales and targeted marketing, norms of cigar and blunt smoking for stress relief, socialization, and cultural participation, and ubiquitous cigar and blunt smoking cues, all of which promoted cigar use in their communities. Future research should further explore how community-level influences contribute to disproportionate cigar use among Black young adults. Our findings suggest that programs and policies addressing physical and sociocultural community-level pro-smoking influences may help mitigate cigar smoking disparities.

Online E-Cigarette Information Exposure and Its Association with E-Cigarette Use among Adolescents in Shanghai, China

E-cigarettes are widely advertised, while the potential risks of e-cigarette use have been reported among adolescents. This study assessed online e-cigarette information exposure and its association with adolescents’ e-cigarette use in Shanghai, China. A total of 12,470 students aged 13–18 years participated. A questionnaire collected information on students’ sociodemographic factors, e-cigarette information exposure, cigarette use, e-cigarette use, and e-cigarette use intention. A multivariate logistic regression was performed to assess correlates of exposure to e-cigarette information and the association between e-cigarette information exposure and e-cigarette use. Overall, 73.9% of students knew about e-cigarettes and the primary sources of information were the internet (42.4%), movies/TV (36.4%), bulletin boards in retail stores or supermarkets (34.9%), advertising flyers (33.9%), and friends (13.8%). Students who had friends using e-cigarettes were curious about e-cigarettes and showed a greater monthly allowance; smokers and females were at a higher risk of social media and website exposure. Moreover, online information exposure (social media exposure, website exposure, and total internet exposure) was significantly associated with the intention to use e-cigarettes. The enforcement of regulations on online e-cigarette content should be implemented. Moreover, efforts to prevent young people from using e-cigarettes may benefit from targeting students at a higher risk of online e-cigarette information exposure.

Use of electronic vaping products and mental health among adolescent high school students in the United States: The moderating effect of sex

Although studies have investigated the association between conventional tobacco smoking and mental health outcomes among adolescents in the United States, few studies have examined the association between electronic vaping products (EVPs) and mental health among adolescents. This study aimed to investigate the cross-sectional association between EVPs use, symptoms of depression, and suicidal behaviors among adolescents. Data were pooled from the 2017 and 2019 Youth Risk Behavior Survey. An analytic sample of 14,285 adolescents (50.3% female) was analyzed using binary logistic regression. The outcome variables investigated were symptoms of depression, suicidal ideation, suicide plan, and suicide attempts, and the main explanatory variable was EVPs use. Of the 14,285 adolescents, 22.2%, 19.2%, and 58.8% were current, former and never users of EVPs, respectively. Controlling for other factors, current users of EVPs were significantly more likely to report having symptoms of depression (AOR = 1.82, 95% CI = 1.58-2.09), having suicidal ideation (AOR = 1.55, 95% CI = 1.30-1.86), making a suicide plan (AOR = 1.62, 95% CI = 1.34-1.97), or attempting suicide (AOR = 1.75, 95% CI = 1.41-2.18) when compared to never users of EVPs. Gender moderated the association between EVPs use, symptoms of depression, suicidal ideation, and suicide plan. Racial minority identity, sexual minority identity, sexual violence victimization, victim of school and cyberbullying, alcohol use, and cigarette smoking were all significantly associated with depression and suicidal behaviors. Study findings support the association between EVPs use and adolescent mental health. Future studies that employ longitudinal designs may offer more insight into the mechanisms underlying this association.