Tactics for Drawing Youth to Vaping: Content Analysis of Electronic Cigarette Advertisements

Youth perspectives on the promotional and public relations strategies of health harming industries

Public health researchers have investigated how youth are exposed to and influenced by traditional forms of commercial marketing from health-harming industries. Limited research has investigated youth opinions about the broader marketing and public relations strategies of these industries. This study aimed to understand youth perceptions of the impact and influence of a range of marketing and public relations strategies used by health harming industries. An online qualitative survey was conducted with n = 518, 16- to 24-year-olds living in Victoria, Australia. Participants were asked to consider the broad influence of marketing from health harming industries on youth, including the impacts of social media promotions, corporate social responsibility strategies including sponsorship and political donations, as well as their views on marketing restrictions. Reflexive thematic analysis was used to construct themes from the data. Participants stated that excessive marketing strategies had a significant influence on youth consumption of health harming products. Most felt that social media marketing had the most appeal and influence on youth. Most were critical of these strategies and were supportive of strong restrictions on marketing for health-harming products. However, many participants held more positive views about corporate social responsibility strategies, which they perceived could offset the negative impacts of these industries on health. Increased focus is needed from the public health and health promotion communities to ensure that youth are protected from the influence of the range of marketing strategies that are used by health-harming industries to promote their products and resist regulatory reform.

Socio-ecological factors that influence youth vaping: perspectives from Western Australian school professionals, parents and young people

PURPOSE

To understand from the perspectives of school professionals, parents and young people the socio-ecological factors that may facilitate and prevent e-cigarette use among young people in Perth, Western Australia.

METHODS

Purposive sampling was used to recruit school professionals, parents and young people for one-on-one (n = 35) or joint (n = 3) interviews (in-person n = 11 or online n = 27). Data were analysed using thematic analysis and classified into four domains based on the socio-ecological model: i) individual, ii) interpersonal, iii) organizational/community and iv) societal/policy.

RESULTS

Factors that were found to support vaping among young people included sensation-seeking and risk-taking behaviour; a low-risk perception of vapes; attractive characteristics of vapes; ease of access; perception vaping is a social activity; and lack of knowledge about vaping among parents and school professionals. Vaping prevention messages originating from the familial, educational and community spheres are lacking but wanted by adults and young people.

CONCLUSIONS

The pervasiveness of the e-cigarette trade and persistent challenges related to surveillance and enforcement need to be addressed to reduce exposure and access to e-cigarettes. A mixture of "hard" and "soft" public policy tools involving key stakeholders in a range of settings is needed to prevent e-cigarette access and uptake by young people.

Intensifying Substance Use Trends among Youth: A Narrative Review of Recent Trends and Implications

PURPOSE OF REVIEW

Substance use among adolescents and young adults remains a critical public health concern, with patterns shifting dramatically in recent years. This narrative review examines trends in substance use behaviors during and following the COVID-19 pandemic.

RECENT FINDINGS

Epidemiologic evidence shows declines in the proportion of youth who are using most substances but intensified consumption patterns with rising levels of disorder among adolescents who use substances. This picture may reflect the greater potency, availability and accessibility of substances, vulnerabilities related to poor mental health, minoritization, as well as social factors including pandemic stressors, commercial and regulatory forces - in short, features of the agent (substance), host (person), and environment (context), consistent with a public health formulation. Understanding trends in youth substance use and related problems, especially in the context of contributing factors, is critical for informing clinical care strategies and public health interventions to improve outcomes for youth across diverse populations.

Assessing the knowledge, attitude and practice of electronic cigarettes and their associated factors among undergraduate students of Institute of Medicine, Nepal: a cross-sectional study

BACKGROUND

Electronic cigarettes (e-cigarettes) are gaining popularity globally and becoming popular among young people, including in Nepal. Easy accessibility, appealing ads, and the misconception that e-cigarettes are safer than traditional cigarettes have fueled their rising popularity among university students in Nepal. The lack of comprehensive data on the prevalence and determinants of e-cigarette use among university students in Nepal underscores the urgent need for targeted research in this area. This study aimed to examine the knowledge, attitudes, and practices regarding e-cigarettes, as well as their influencing factors, among undergraduate students at the Institute of Medicine in Kathmandu, Nepal.

METHODS

We conducted a cross-sectional study with 302 undergraduate students. A self-administered questionnaire assessed their knowledge, attitudes, and practices related to e-cigarettes. Descriptive statistics were reported, and chi-square tests and multivariate logistic regression analyses were performed to determine the statistical association among variables using STATA 14.

RESULTS

The mean age of participants was 21.4 ± 2.1 years. Of the 302 respondents, 214 (70.9%) had heard of e-cigarettes. Among them, 71.5% had good knowledge, 62.2% held supportive attitudes, and 79.0% had never used e-cigarettes. Males were more likely to smoke e-cigarettes than females (AOR: 2.27; 95% CI: 1.01-5.01; p = 0.046). Students with friends who smoke were nearly three times more likely to use e-cigarettes (AOR: 3.00; 95% CI: 1.12-7.99; p = 0.028). Supportive attitudes towards e-cigarettes also doubled the likelihood of smoking them (AOR: 2.10; 95% CI: 1.02-4.35; p = 0.045).

CONCLUSION

The study highlights important implications for interventions, policy, and education within Nepal's medical system. With a notable percentage of students holding supportive attitudes toward e-cigarettes, there is a clear need for targeted behavior change campaigns that educate about the health risks associated with e-cigarettes.

Examining the e-cigarette scenario based on distribution, availability, marketing, and banning: A GIS-Based qualitative study in Bangladesh

BACKGROUND

Globally, over 81 million people use e-cigarettes, and the majority of them are young adults. Using e-cigarettes causes different types of adverse health effects both in adults and elderly people. Over time, using e-cigarettes has detrimental consequences on lung function, brain development and numerous other illnesses.

METHODS

This study employed a mixed-methods conducted between June and September 2023, comprising two phases: Geographical Information System (GIS) mapping of available e-cigarette point-of-sale (POS) locations and conducting 15 in-depth interviews (IDIs) with e-cigarette retailers, along with 5 key informant interviews (KIIs) involving tobacco control activists and policy experts. ArcGIS was employed for spatial analysis, creating distribution and type maps, and buffer and multi-buffer ring analyses were conducted to assess proximity to hospitals and academic institutions. Data analysis involved descriptive statistics for GIS mapping and qualitative analysis for interview transcripts, utilizing a priori codebook and thematic analysis.

RESULTS

A total of 276 POS were mapped in the entire Dhaka city. About 55 POS were found within 100m distance from academic institutions in Dhaka city, which offers the easy accessibility of young generations to e-cigarettes. The younger generation is becoming the major target for e-cigarettes because of their alluring flavors, appealing looks, and variation in flavors. Sellers have been using different marketing tactics such as postering, offering discounts and using internet marketing on social media. Moreover, they try to convince the customers by saying that e-cigarettes are 'not harmful' or 'less harmful'. However, retailers were mostly taking e-cigarettes from local wholesalers or distributors. Customers buy these products both from in-store and online services. Due to the absence of laws and regulations on e-cigarettes in Bangladesh, the availability, marketing, and selling of e-cigarettes are increasing alarmingly.

CONCLUSION

E-cigarette retail shops are mostly surrounded by academic institutions, and it is expanding. Besides, frequent exposure, easy accessibility, and tactful promotion encourage the younger generations to consume e-cigarettes. The government should take necessary control measures on manufacturing, storage, advertising, promotion, sponsorship, marketing, distribution, sale, import, and export in order to safeguard the health and safety of young and future generations.

Social Media Marketing Strategies for Electronic Cigarettes: Content Analysis of Chinese Weibo Accounts

BACKGROUND

E-cigarettes have gained popularity among teenagers due to extensive marketing strategies on social media platforms. This widespread promotion is a risk factor, as it fosters more positive attitudes toward e-cigarette use among teenagers and increases the perception that using e-cigarettes is normal. Therefore, the marketing of e-cigarettes on social media is a serious global health concern, and its strategies and impact should be clearly identified.

OBJECTIVE

This study examined how e-cigarette companies popularize their products via Weibo and identified the specific strategies influencing the effectiveness of their marketing.

METHODS

In phase 1, we conducted a search on Qcc.com and identified 32 e-cigarette brands with active Weibo accounts between October 1 and December 31, 2020, along with 863 Weibo posts. The data were investigated through content analysis. The codebook was developed into four categories: (1) product and features, (2) sales and promotions, (3) social contact and interaction, and (4) restrictions and warnings. To further understand the factors influencing e-cigarette brand marketing, we conducted a multiple linear regression analysis.

RESULTS

Marketing tactics by e-cigarette companies on Chinese social media were documented, including emphasizing attractive product features, using trendy characters, implicit promotions, downplaying health concerns, and engaging with Weibo users in various ways. Out of 863 posts, 449 (52%) mentioned product characteristics. In 313 (36.3%) posts, visible figures were used to attract attention. Product promotion was absent in 762 (88.3%) posts, and purchase channels were not mentioned in 790 (98.3%) posts. Social interaction-related posts received attention (n=548, 63.5%), particularly those featuring hashtag content (n=538, 62.3%). Most posts did not include claims for restrictions on teenagers' purchases or use (n=687, 79.6%) or information on health warnings (n=839, 97.2%). Multiple linear regression analysis identified marketing strategies that effectively increase the exposure of e-cigarette posts on Weibo. Posts including engagement via posts encouraging reposts, comments, and likes (P<.001) and engagement topics related to e-cigarette brands were positively correlated with the number of reposts (P=.009). Posts highlighting nonmonetary incentives (P=.004), posts with age restriction statements (P<.001), engaging via stories and idea collection (P<.001), and engagement topics related to products (P<.001) and current affairs (P=.002) had a positive effect on the number of comments. Engagement topics related to brands (P<.001) or interactive sweepstakes (P<.001) had a positive effect on the number of likes.

CONCLUSIONS

E-cigarette posts on Weibo that focus on product features and social interaction attract public attention, especially from teenagers. Stricter regulations and monitoring should be adopted to restrict the social media marketing of e-cigarettes.

Choice of smoking cessation products among people with substance use problems in the US: Findings from the Population Assessment of Tobacco and Health (PATH) study Wave 6

OBJECTIVE

The aim of this study was to compare past 12-month use of cigarette smoking cessation aids (e.g., Food and Drug Administration (FDA)-approved cessation products or e-cigarettes for smoking cessation) among people with substance use problems (PWSUPs) who currently smoke to people without substance use problems (SUPs) who currently smoke cigarettes in a nationally representative US sample.

METHODS

We used the Population Assessment of Tobacco and Health (PATH) Wave 6 Study [n = 30,516]. Our sample comprised adult (18+) established cigarette smokers (100+ lifetime-sticks with daily/non-daily use) [n = 5,895]. The independent variable was SUP status (no, moderate, and high). The dependent variables were past-year use of: nicotine replacement therapies (NRTs), cessation medications [i.e., varenicline or bupropion], or e-cigarettes [for cigarette cessation and reduction]. Weighted multivariable logistic regression models for each dependent variable examined the associations between SUP status and each cessation aid, adjusting for cigarette dependence, daily cigarette smoking, and demographic factors.

RESULTS

Among people who smoke, a higher proportion of respondents with high SUP severity used NRTs, cessation medications, and e-cigarettes for cigarette cessation, respectively (12.3%, 8.4%, 15.7%), compared to those with no/low SUP severity (9.8%, 6.0%, 8.9%). In the multivariable models, respondents with high SUPs had 63% (95% CI:1.16-2.29) higher odds of using e-cigarettes for cessation than those without SUPs. No significant differences were seen between high (vs. no/low SUPs) in the past-year use of NRTs and cessation medications.

CONCLUSION

Our findings indicate that cigarette smokers with high SUPs had higher odds of using e-cigarettes for cessation and reduction compared to smokers without SUPs.

An integrated dual process model in predicting e-cigarette use in undergraduate students

The use of e-cigarette or vape devices is a growing concern on an international scale, given the devices' addictive nature and questions regarding their short- and long-term health impacts. Their use is especially an issue in young people, many of whom have little or no previous nicotine use experience. This study tested an integrated dual process model in 363 young Australian undergraduates where prospectively measured e-cigarette use was predicted by the psychological constructs of the theory of planned behavior, supplemented with risk perception, e-cigarette dependence, habit, and implicit attitude. Intention to use an e-cigarette was predicted by affective attitude, subjective norm, and e-cigarette dependance, but not instrumental attitude, perceived behavioral control, or risk perception. E-cigarette use was predicted by e-cigarette dependance, intention, habit, implicit attitude, and previous nicotine use, although perceived behavioral control did not directly predict behavior nor moderate the intention-behavior relationship. Current findings provide evidence for important psychological predictors of e-cigarette use, signposting potential intervention targets. Specifically, interventions may benefit from using strategies that tap affective or normative beliefs alongside automatic constructs and dependence, while focusing less on beliefs about the health impacts of e-cigarettes or control over using.

New image, same tactics: global tobacco and vaping industry strategies to promote youth vaping

E-cigarette use (or vaping) is widespread in young people and is a rapidly growing public health problem. While the tobacco and vaping industry has promoted vaping as a smoking cessation aid for adults, the industry has strategically targeted young people through marketing and appealing designs to orientate a new generation of consumers to use their products. These strategies are not new and replicate what we have previously seen employed by the tobacco industry in past decades to maintain and grow their tobacco profits. We review the evidence on tobacco and vaping industry interference, highlighting the calculated and strategic use of interference tactics as a discourse to curb tobacco control efforts. We demonstrate how these tried and tested strategies are now being purposefully re-used in the context of vaping. As Australia is currently undergoing significant policy reforms for the access and retail of vaping products, we also provide a case study of the industry response played out in this contemporary landscape. Government and public health advocates are in a key position to be one step ahead in proactively tackling the vaping crisis. We recommend that continued monitoring of industry activities and strategies, achieving political transparency and tightening loopholes in current regulations are all needed to identify and eliminate the tobacco and vaping industry's influence on policymaking. Given their previous track record, we emphasize the need to counter industry interference tactics with urgency to prevent a new generation of nicotine dependence and to support and protect future action in tobacco control.

A Qualitative Analysis of How Underage Adolescents Access Nicotine Vaping Products in Aotearoa New Zealand

INTRODUCTION

Despite policies setting a minimum legal sales age, youth continue to access electronic cigarettes (ECs). Evidence of rising youth vaping prevalence in many countries suggests existing measures have serious loopholes and raise important questions about how youth source vaping products.

AIMS AND METHODS

We explored how youth source ECs using in-depth interviews with 30 adolescents aged 16-17 who vaped at least once a month and lived in Aotearoa New Zealand. Our semistructured interview guide probed participants' vaping experiences and how they developed and used social, quasi-commercial, and commercial supply routes to access ECs. We used an inductive reflexive thematic analysis approach to interpret the data.

RESULTS

Nearly all participants shared ECs with peers and sharing was the sole access route for some. Many used proxies, often older relatives or people they knew socially, to purchase ECs on their behalf; however, others recruited proxies by approaching previously unknown people they identified on social media. Participants also sourced ECs via quasi-commercial networks that existed within schools and on social media, and some purchased in their own right, usually from smaller retail outlets that did not ask for ID.

CONCLUSIONS

Disrupting social supply will be challenging, though reducing ECs' availability, appeal, and affordability could make social supply, including sharing and proxy purchasing, more difficult. Reports that youth purchase ECs from commercial retailers known to waive age verification suggest stronger monitoring and enforcement, along with escalating retailer penalties, are required.

IMPLICATIONS

Vaping access routes sit on a continuum from informal, spontaneous sharing to carefully planned commercial purchases. While supply via friends, siblings and other social contacts is an important means of access, nicotine dependence drives some to use riskier access routes, including approaching unknown people to act as proxy purchasers. Evidence young people identify noncompliant retailers suggests policy makers should monitor and enforce existing measures more stringently and consider additional penalties for recidivist underage suppliers. A more comprehensive response that reduces the appeal, addictiveness, affordability, and availability of vaping products would address factors fostering and maintaining youth vaping.

Behavioral Precursors of Nicotine Product Use Trajectories Among Youth

INTRODUCTION

Preventing nicotine use among youth is a public health priority. Nicotine use emerges from complex relationships between numerous factors. This project used network analysis to model behavioral precursors of nicotine use (knowledge, attitudes, perceptions, intentions) among youth who had never used nicotine and determine which predicted future trajectories of use across multiple nicotine products.

METHODS

Data were from the Population Assessment of Tobacco and Health study (2013-2018; analyzed 2023-2024), youth ages 12-17, who reported never using nicotine at Wave 1. Network structure was determined for behavioral precursors at Wave 1 and central network nodes were identified (N=5,087). Central nodes were then tested as predictors of trajectories of use across multiple nicotine products during Waves 1-4 (N=3,851).

RESULTS

Central nodes of the Wave 1 network were harm perception, expectancy that tobacco would calm anger/reduce stress, and intention to try. Those with lower intent to try at Wave 1 had lower odds of being in an Experimentation or Use class versus a Nonuse class during Waves 1-4 (p<0.0001). Those with more accurate harm perception had lower odds of being in an Experimentation versus Nonuse class (p=0.004). Those with positive expectancies had higher odds of being in an Experimentation versus Nonuse or Use class (p=0.04, 0.02).

CONCLUSIONS

Findings suggest a network model of behavioral precursors of nicotine use that can be tested, including central nodes that predicted trajectories of use across multiple nicotine products, and therefore may be priority intervention targets.

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.

Perception of e-cigarette control policies and education in schools on increased legal knowledge, harm perception, susceptibility and e-cigarette use among students in Thailand: A cross-sectional classroom-based survey

INTRODUCTION

In Thailand, school smoke-free policies initially targeted cigarette smoking but now extend to include electronic cigarettes (e-cigarettes). Yet, the impact of this expansion on curbing e-cigarette use in schools is uncertain. This study seeks to explore how e-cigarette control policies and educational initiatives in Thai secondary schools influence students' legal knowledge, perception of harm, current e-cigarette use, and susceptibility to future use.

METHODS

This cross-sectional survey was conducted in four regions of Thailand between May and August 2023, involving 6147 students selected through multistage sampling. Data collection utilized a self-reported online questionnaire in Thai, developed using Google Forms. For continuous outcomes, multiple linear regression models assessed relationships between school e-cigarette policy perceptions, covariates, knowledge of e-cigarette laws, and harm perception. Multiple logistic regression models analyzed the association between policy perceptions, covariates, and categorical outcomes: current e-cigarette use and susceptibility.

RESULTS

Adjusting for covariates, a positive association was found between students' perceptions of e-cigarette policies and teachings and their knowledge of e-cigarette control laws (B=0.083, p<0.001) and harm perceptions (B=0.491, p<0.001). Additionally, these perceptions were protective against current e-cigarette use (AOR=0.970; 95% CI: 0.95-0.99, p=0.002) and susceptibility among non-users (AOR=0.962; 95% CI: 0.95-0.97; p<0.001).

CONCLUSIONS

A heightened perception of e-cigarette policies and teachings in schools is associated with increased legal knowledge, heightened harm perception, and a lower likelihood of current or future e-cigarette use. This underscores the importance of enforcing the e-cigarette-free policy in schools to mitigate vaping susceptibility amid the ongoing youth e-cigarette epidemic.

Electronic cigarette social norms among adolescents in New South Wales, Australia

The use of electronic cigarettes (e-cigarettes) is common and increasing, especially among youth. In 2022/2023, 30% of 12- to 17-year-olds reported ever using e-cigarettes in Australia-a >50% increase from 2017 (14%). Several adverse e-cigarette health effects have been identified and most effects remain unknown. Social norms, rules that govern social behaviours, are associated with current and future adolescent e-cigarette use. Understanding social norms in Australian adolescents is critical to the development of targeted and effective e-cigarette prevention activities. This study aims to explore e-cigarette social norms among adolescents living in New South Wales, Australia. A total of 32 online single or paired semi-structured qualitative interviews were conducted involving 46 participants aged 14-17 years, as part of the Generation Vape project. Reflexive thematic analysis was applied within a constructivist perceptive. Adolescents perceived e-cigarettes use as prolific among their peers, with use considered common, acceptable and normal. Fuelled by social exposure to e-cigarettes, 'everyone' was generally thought to be using them (descriptive norms). E-cigarette use was considered so entrenched that it was part of adolescent identity, with abstinence regarded as atypical. Use was driven by an internalised desire to fit it (injunctive norm), rather than being attributed to overt/external 'peer-pressure'. Positive e-cigarette norms exist among Australian adolescents with norm formation strongly influenced by social exposure, including e-cigarette promotion. Prevention efforts should include limiting adolescent exposure to e-cigarette marketing to help redefine existing pro-e-cigarette social norms and protect health.

Perceiving E-Cigarettes as Safe and Safer Alternative to Cigarettes Among Young Adults

BACKGROUND

Young adults are using e-cigarettes at high rates. While the literature on the health risks associated with e-cigarettes is extensive and growing, little is known about young adults' thoughts and perceptions of the safety and harms of e-cigarettes.

METHODS

We conducted one-on-one interviews with young adults aged 18 to 25 years in Los Angeles, California between June 2018 and June 2019. We interviewed and audio-recorded young adults (N = 62) who consented to the study and self-reported to have used e-cigarettes on a weekly basis or more for at least 5 months prior to study enrollment. Interviews examined participants' thoughts, feelings, and experiences related to e-cigarette use. We audio-recorded, transcribed, and coded the interviews using grounded theory analysis methods.

RESULTS

Young adults often believed that e-cigarettes were safer than cigarettes and were safe to use, especially following positive vaping experiences. Young adults were skeptical of the available science on e-cigarette use and felt there was not conclusive data on the harms of e-cigarettes. In their selection of e-cigarettes over cigarettes, young adults felt they were making a conscious and healthier choice. Because young adults viewed e-cigarettes to be better for them based on their personal experiences with vaping, they felt e-cigarettes were a superior alternative to combustible tobacco.

CONCLUSIONS

Young adults in our study believed that the long-term health effects of e-cigarette use are not clearly understood and were generally skeptical of the research on e-cigarette harms. Policy, education, and anti-smoking campaigns need to clarify the negative health-related consequences of e-cigarette use for young people.

Tobacco market trends in 97 countries between 2007 and 2021

INTRODUCTION

Analysis of the tobacco market can provide valuable insights for developing tobacco control strategies. This study examines the market trends of cigarettes, cigars/cigarillos, smoking tobacco, smokeless tobacco, e-cigarettes, heated tobacco products (HTPs), and tobacco-free oral nicotine, across 97 countries between 2007 and 2021.

METHODS

We obtained annual tobacco retail value data from Euromonitor Passport and calculated the market share for each type of tobacco product. The research examined trends in retail value and market share globally, stratified by national income level, as well as in individual countries.

RESULTS

From 2007 to 2015, the growth of the global tobacco market was primarily driven by cigarette sales. However, starting in 2016, emerging products, including e-cigarettes, HTPs, and tobacco-free oral nicotine, as well as non-cigarette combustible products, including cigars/cigarillos and smoking tobacco, have been mostly responsible for the increases in the global tobacco retail value. High-income countries experienced the greatest increase in the retail value of emerging products, while middle- and low-income countries still observed rises in cigarette sales.

CONCLUSIONS

Trends in the retail value of different tobacco products varied widely during the study period, with distinct trends observed in different income levels and within individual countries. These trends can supplement prevalence data and be used to inform local tobacco control policies.

The commercial promotion of electronic cigarettes on social media and its influence on positive perceptions of vaping and vaping behaviours in Anglophone countries: A scoping review

There is ongoing scientific and policy debate about the role e-cigarettes play in tobacco control, with concerns centring around unknown long-term effects, and the potential industry co-option of harm reduction efforts, including marketing to youths. There is substantial evidence of the influence of conventional cigarette promotion on smoking behaviours in Anglophone countries, and the popularity of social networking sites, as well as the lack of marketing regulations on the commercial promotion of electronic cigarettes online, suggest an urgent need to explore this topic further. This scoping review aims to map the existing evidence related to the influence of e-cigarette commercial promotion on social media on positive perceptions of vaping and vaping behaviours in core Anglophone countries. Searches were conducted in CENTRAL, Cochrane Database of Systematic Reviews (CDSR), Embase, Epistemonikos, MEDLINE, PsycINFO and Science Citation Index, on the 21st of July 2022. From 1,385 studies, 11 articles were included in the final review, using diverse study designs, including focus groups, content analysis, cross-sectional studies, and experiments. The studies were primarily based in the U.S. and evidenced the association between the commercial promotion of e-cigarettes on social media with positive perceptions of vaping and vaping behaviours, particularly among young people, addressing diverse themes including celebrities' sponsorship, e-liquid appeal (including flavours and nicotine levels), users' engagement with ads, and other marketing strategies. Further, social networking sites commercially promoting e-cigarettes might increase positive attitudes towards vaping and vaping behaviours, particularly among youths. Future research should be conducted in broader settings, incorporate larger and diverse sample sizes, ensure research transparency, cover multiple social networking sites, emphasize ecological validity, and foment longitudinal studies.

Prevalence and Covariates of Electronic Cigarette Use among Students Aged 13-15 Years in the Philippines: 2019 Global Youth Tobacco Survey

Electronic cigarette use is growing in popularity and accessibility among youth in the Southeast Asia region. We analyzed data on 6670 students, aged 13-15 years, from the Philippines' 2019 Global Youth Tobacco Survey. Prevalence estimates and 95% confidence intervals (CI) were estimated for current use (i.e., past 30 days), ever use, and awareness of e-cigarettes. Chi-square tests compared prevalence differences between groups. Multiple logistic regression models assessed factors associated with e-cigarette use while controlling for sociodemographic characteristics, current use of other tobacco products, and secondhand smoke exposure. Prevalence of current e-cigarette use was 14.1% (95% CI = 12.4%, 15.8%), ever use was 24.6% (95% CI = 22.4%, 26.9%), and awareness was 75.5% (95% CI = 73.0%, 78.0%). Current use of any other tobacco products and exposure to secondhand smoke at home, school, or other public places were positively associated with current and ever use of e-cigarettes. Boys and youth living in Luzon or Mindanao had higher odds of current e-cigarette use compared to girls and youth in Visayas. Findings indicated that one in four Philippine students aged 13-15 years ever used e-cigarettes and one in seven currently use e-cigarettes. This study highlights the importance of implementing evidence-based strategies, including relevant tobacco control policies.

Strengths and Limitations of Web-Based Cessation Support for Individuals Who Smoke, Dual Use, or Vape: Qualitative Interview Study

BACKGROUND

Tobacco use has shifted in recent years, especially with the introduction of e-cigarettes. Despite the current variable and intersecting tobacco product use among tobacco users, most want to quit, which necessitates cessation programs to adapt to these variable trends (vs focusing on combustible cigarettes alone). The use of web-based modalities for cessation support has become quite popular in recent years and has been compounded by the COVID-19 pandemic. Therefore, understanding the current strengths and limitations of existing programs to meet the needs of current various tobacco users is critical for ensuring the saliency of such programs moving forward.

OBJECTIVE

The purpose of this study was to understand the strengths and limitations of web-based cessation support offered through QuitNow to better understand the needs of a variety of end users who smoke, dual use, or vape.

METHODS

Semistructured interviews were conducted with 36 nicotine product users in British Columbia. Using conventional content analysis methods, we inductively derived descriptive categories and themes related to the strengths and limitations of QuitNow for those who smoke, dual use, or vape. We analyzed the data with the support of NVivo (version 12; QSR International) and Excel (Microsoft Corporation).

RESULTS

Participants described several strengths and limitations of QuitNow and provided suggestions for improvement, which fell under 2 broad categories: look and feel and content and features. Shared strengths included the breadth of information and the credible nature of the website. Individuals who smoke were particularly keen about the site having a nonjudgmental feeling. Moreover, compared with individuals who smoke, individuals who dual use and individuals who vape were particularly keen about access to professional quit support (eg, quit coach). Shared limitations included the presence of too much text and the need to create an account. Individuals who dual use and individuals who vape thought that the content was geared toward older adults and indicated that there was a lack of information about vaping and personalized content. Regarding suggestions for improvement, participants stated that the site needed more interaction, intuitive organization, improved interface esthetics, a complementary smartphone app, forum discussion tags, more information for different tobacco user profiles, and user testimonials. Individuals who vape were particularly interested in website user reviews. In addition, individuals who vape were more interested in an intrinsic approach to quitting (eg, mindfulness) compared with extrinsic approaches (eg, material incentives), the latter of which was endorsed by more individuals who dual use and individuals who smoke.

CONCLUSIONS

The findings of this study provide directions for enhancing the saliency of web-based cessation programs for a variety of tobacco use behaviors that hallmark current tobacco use.

Smartphone Apps Targeting Youth Tobacco Use Prevention and Cessation: An Assessment of Credibility and Quality

Purpose of Review

The goals of this study were to identify smartphone apps targeting youth tobacco use prevention and/or cessation discussed in the academic literature and/or available in the Apple App Store and to review and rate the credibility of the apps. We took a multiphase approach in a non-systematic review that involved conducting parallel literature and App Store searches, screening the returned literature and apps for inclusion, characterizing the studies and apps, and evaluating app quality using a standardized rating scale.

Recent Findings

The negative consequences of youth tobacco use initiation are profound and far-reaching. Half of the youth who use nicotine want to quit, but quit rates are low. The integration of smartphone apps shows promise in complementing and enhancing evidence-based youth tobacco prevention and treatment methods.

Summary

Consistent with prior reviews, we identified a disconnect between apps that are readily accessible and those that have an evidence base, and many popular apps received low quality scores. Findings suggest a need for better integration between evidence-based and popular, available apps targeting youth tobacco use.

A Content Analysis of Behavior Change Techniques Employed in North American Vaping Prevention Interventions

Introduction

Vaping among North American youth has surfaced as a concerning public health epidemic. Increasing evidence of harms associated with E-cigarette use, especially among the young, has prompted urgency in addressing vaping. Although a number of individual behavior change campaigns have arisen as a result, little is known about which behavior change techniques are being employed to influence youth vaping behavior. In this study, we aimed to code all North American vaping prevention campaigns using the behavior change technique taxonomy (Version 1) to determine which behavior change techniques are being used.

Methods

We identified the sample of campaigns through systematic searches using Google. After applying the exclusion criteria, the campaigns were reviewed and coded for behavior change techniques.

Results

In total, 46 unique vaping prevention campaigns were identified, including 2 federal (1 from Canada, 1 from the U.S.), 43 U.S. state-level, and 1 Canadian provincial-level campaign(s). The number of behavior change technique categories and behavior change techniques in a campaign ranged from 0 to 5 (mean=1.56) and 0 to 6 (mean=2.13), respectively. Of the 16 possible behavior change technique categories, 4 were utilized across the campaigns, which included 5. Natural consequences (89%), 6. Comparison of behavior (22%), 13. Identity (20%), and 3. Social support (11%).

Conclusions

Only a small number of behavior change techniques were used in North American vaping prevention campaigns, with a heavy and often sole reliance on communicating the health consequences of use. Incorporating other promising behavior change techniques into future campaigns is likely a productive way forward to tackling the complex and multifaceted issue of youth vaping.

How do underage youth access e-cigarettes in settings with minimum age sales restriction laws? A scoping review

BACKGROUND

Despite measures to reduce young people's access to electronic cigarettes (ECs), or "vapes", many countries have recorded rising youth vaping prevalence. We summarised studies documenting how underage youth in countries with minimum age sales restrictions (or where sales are banned) report accessing ECs, and outline research and policy implications.

METHODS

We undertook a focused literature search across multiple databases to identify relevant English-language studies reporting on primary research (quantitative and qualitative) and EC access sources among underage youth.

RESULTS

Social sourcing was the most prevalent EC access route, relative to commercial or other avenues; however, social sourcing dynamics (i.e., who is involved in supplying product and why) remain poorly understood, especially with regard to proxy purchasing. While less prevalent, in-person retail purchasing (mainly from vape shops) persists among this age group, and appears far more common than online purchasing.

CONCLUSIONS

Further research examining how social supply routes operate, including interaction and power dynamics, is crucial to reducing youth vaping. Given widespread access via schools and during social activities and events, exploring how supply routes operate and evolve in these settings should be prioritized. Inadequate compliance with existing sales regulations suggest greater national and local policy enforcement, including fines and licence confiscation for selling to minors, is required at the retailer level.

Awareness and beliefs about FDA e-cigarette regulation in the premarket application review era

INTRODUCTION

In March 2022, FDA granted its first marketing orders for e-cigarettes. Few studies have assessed awareness of FDA e-cigarette regulation and authorization in the era of premarket review. This study describes prevalence of awareness as well as beliefs about regulation among adults who smoke and youth.

METHODS

We conducted a cross-sectional, nationally representative online survey of 866 adults who currently smoke cigarettes and 859 youth (ages 15-20) in June 2022 using Ipsos KnowledgePanel. Population prevalence of regulatory awareness and beliefs are reported. Pearson χ2 and multivariable logistic regressions were conducted to assess dependent and independent associations with demographic and tobacco use characteristics.

RESULTS

Awareness that FDA regulates e-cigarettes was low among adults who smoke (25.4 %) and youth (18.5 %). Awareness that FDA authorizes e-cigarettes was also low among adults who smoke (10.8 %) and youth (12.7 %). Agreement with both positive and negative beliefs regarding FDA e-cigarette regulation was below 50 %. Current e-cigarette use was significantly associated with agreeing that regulation: makes e-cigarettes safer (adult aOR: 2.90, youth aOR: 2.51), helps prevent youth initiation (adult aOR 1.92), takes away freedom to choose to use e-cigarettes (adult aOR: 3.02, youth aOR: 2.58), and limits types of e-cigarettes available (adult aOR: 2.22, youth aOR: 2.49).

DISCUSSION

There is low awareness of FDA e-cigarette regulation and authorization and relatively low agreement with positive beliefs about e-cigarette regulation. Further study is needed to assess how the changing regulatory environment impacts product perceptions, intentions, and behaviors.

Social, educational, and psychological health correlates of e-cigarette and combustible cigarette use among adolescents in the US from 2015 to 2021

BACKGROUND

The prevalence of e-cigarette and vaping products has increased in the past decade, especially among adolescents. To provide data that will inform identification of youth at high risk, the goals of this study are to determine the social, educational, and psychological health outcomes associated with e-cigarette use distinct from combustible cigarettes.

METHODS

Annual samples of adolescents in grade 12 (years: 2015-2021, N = 24,015) were analyzed from Monitoring the Future cross-sectional data. Students were categorized based on vaping and smoking patterns (no use, vape only, combustible cigarette smoking only, or both). Survey-weighted prevalence and logistic regression were used to assess associations.

RESULTS

Between 2015 and 2021, 78.7% of students used neither e-cigarettes nor combustible cigarettes, 13.2% used e-cigarettes only (vape-only), 3.7% used combustible cigarettes only (smoke-only), and 4.4% used both. Students who vaped-only (OR:1.49, CI:1.28-1.74), smoked-only (OR:2.50, CI:1.98-3.16), or both (OR:3.03, CI:2.43-3.76) had worse academic performance than non-smoking, non-vaping peers after demographic adjustment. There was no significant difference in self-esteem between the "neither" group and the other groups, though the "vaping-only", "smoking-only" and "both" groups were more likely to report unhappiness. Inconsistent differences emerged regarding personal & family beliefs.

CONCLUSIONS

Generally, adolescents who reported e-cigarette-only use had better outcomes than their peers who smoked cigarettes. However, students who vape-only reported poorer academic performance compared to those who did not vape or smoke. Vaping and smoking were not significantly related to self-esteem, but were linked to unhappiness. Still, vaping does not follow the same patterns as smoking, despite frequent comparisons in the literature.

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

OBJECTIVE

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

DESIGN

Semistructured discussion groups.

SUBJECTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Predictors of polysubstance vaping in emerging adults

BACKGROUND

Polysubstance use, which increases the risk for negative consequences of substance use, is common among emerging adults who regularly consume substances by vaping. Examining predictors of polysubstance vaping is crucial for understanding whether this novel form of substance consumption lends itself equally efficaciously to established forms of intervention for smoked substances.

OBJECTIVE

The current study aimed to examine whether modifiable cognitive risk factors for increased vaping in the form of attitudes, expectancies and norms can predict co-use of nicotine and cannabis among vapers over and above the effect of demographics, personality risk factors and anxiety, depression symptoms.

METHODS

Regular nicotine and cannabis vapers between 18 and 30 years were recruited online in Canada via a Qualtrics panel. Hierarchical binary logistic regression was used to predict membership in a polysubstance or a single substance vaping group. Demographics, personality risk factors, depression and anxiety symptoms were included as predictors in block 1; attitudes, expectancies and perceived norms of vaping were added in block 2.

RESULTS

Attitudes, expectancies and norms predicted polysubstance use over and above the effect of demographics, personality risk factors and anxiety, depression symptoms. Positive expectancies played a uniquely significant role in the prediction of polysubstance vaping.

CONCLUSIONS

Cognitive interventions targeting attitudes, expectancies and norms may be effective in prevention of polysubstance vaping, although positive expectancies appear to be the main unique factor that has an influence above and beyond all other cognitive factors related to vaping. Treatment and prevention programs should put special focus on lowering positive expectancies.

How Does Online e-cigarette Advertisement Promote Youth's e-cigarettes Use? The Mediating Roles of Social Norm and Risk Perceptions

The adoption of the internet, social media, and e-cigarettes are on the rise among U.S. youth. Uses of social media and online platforms increase the probability for youth to encounter e-cigarette advertisements. Departing from this line of reasoning, we examine the underlying mechanisms of how online e-cigarettes exposure promotes youth's e-cigarette use. Drawing on insights from the social construction of risk model, this study looks at how perceived social norms and risk perception mediate the link between online e-cigarette advertisement exposure and e-cigarette use. Youth aged 12-17 from the Public Assessment of Tobacco and Health (PATH) Study Waves 2-4 (2014-2018) were included (N = 6,067). Controlling for demographic and other known risk factors for e-cigarette use, respondents who had been exposed to online e-cigarette ads at Wave 2 perceived higher levels of positive social norms of e-cigarette use at Wave 3 (β = 0.13, p < .001) which was associated with lower e-cigarette risk perception at Wave 3 (β = -0.22, p < .001). Lower e-cigarette risk perception at Wave 3 resulted in a higher likelihood of e-cigarette use at Wave 4 (AOR = 0.51, p < .001). Online e-cigarettes ads exposure at Wave 2 predicted e-cigarette use at Wave 4 (AOR = 1.87, p < .001). The results indicate that norm perception associated with online e-cigarettes ads may twist youth's e-cigarette risk perception that is associated with subsequent usage. Interventions to curb youth's e-cigarette use can target social norms of e-cigarette use and restrict e-cigarette advertisement exposure to youth.

Vaping Among Adolescents: An Overview of E-Cigarette Use in Middle and High School Students in India

E-cigarette use among middle and high school students has become a growing public health concern in recent years. The prevalence of e-cigarette use among adolescents has increased dramatically, and there are serious health risks associated with this behavior. This review article provides an overview of e-cigarette use in middle and high school students, including the prevalence of use, contributing factors, health effects, policies and regulations surrounding e-cigarette use in schools, and interventions for preventing e-cigarette use in adolescents. The article highlights the need for effective prevention and cessation programs, increased public awareness about the risks of e-cigarette use, and stronger regulations on e-cigarette products. Addressing e-cigarette use among youth is critical for protecting the health and well-being of future generations, and it is important for parents, educators, healthcare providers, and policymakers to work together to prevent and reduce e-cigarette use among adolescents and promote healthy behaviors.

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.

Challenges and opportunities associated with e-cigarettes in Australia: A qualitative study

OBJECTIVE

The use of e-cigarettes in Australia has increased significantly in recent years. To assist with identifying policy and practice priorities, this study sought to provide a greater understanding of the population-level challenges and opportunities associated with these products.

METHODS

Semi-structured interviews were conducted with 34 public health experts working in tobacco- and/or nicotine-related policy, practice and research. Interview transcripts were subject to reflexive thematic analysis.

RESULTS

Several challenges associated with e-cigarettes were identified, with uptake of use among youth, the potential for use to lead to smoking and industry interference the most frequently mentioned. Recommended means of addressing these challenges included improved regulation and increased enforcement of existing laws. Most interviewees acknowledged some potential for e-cigarettes to assist with smoking cessation.

CONCLUSIONS

Despite strong restrictions on e-cigarettes in Australia, experts working in this field reported that these products, and the companies behind them, present several challenges to public health.

IMPLICATIONS FOR PUBLIC HEALTH

Tighter regulation and increased enforcement are needed to address the challenges posed by e-cigarettes. Controlled access to liquid nicotine under a pharmaceutical model offers an opportunity for smokers to access the behavioural support that may help them to quit while also restricting e-cigarette availability.

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.

A content analysis of promotional features in US direct-mail from ads across tobacco products from 2018-2020

INTRODUCTION

Direct-mail advertising is a crucial channel through which tobacco companies deliver price incentives that lower the barrier to tobacco use while promoting tobacco products via thematic appeals not legally permitted on other marketing channels. We examine the prevalence of price incentives and ad characteristics used in tobacco product ads mailed directly to US consumers.

METHODS

We analyzed the content of direct-mail tobacco advertisements (N= 1047) in circulation between January 2018 and December 2020 as captured by Mintel Comperemedia Direct. These ads were coded for product type, manufacturer/brand type, model characteristics, price incentives, and themes known to appeal to vulnerable subgroups.

RESULTS

Ads across all tobacco products included price incentives (96%) and contained themes that appealed to rural white (40%) and black audiences (15%). Themes known to appeal to youth and young adults were present in 40% of ads across all products, including 78% of ads promoting electronic nicotine delivery systems (ENDS). Moreover, among the ENDS ads featuring youth appealing themes (51%), also featured young models.

DISCUSSION

Expanding on previous research which focused on combustible and smokeless tobacco products, this analysis examines direct-mail ads across the full range of tobacco products. Our findings highlight the need for regulations to address 1) the high prevalence of price incentives which undermine the effectiveness of excise taxes on tobacco use, and 2) ad themes and characteristics that appeal to groups vulnerable to tobacco use, both of which have the potential to further exacerbate tobacco related health disparities.

IMPLICATIONS

This study reinforces the importance of examining direct-mail as the dominant medium for tobacco advertising, particularly by including coupons and discount codes that reduce product price and thus circumventing the effect of tobacco-related tax legislation.Direct-mail encourages continued product loyalty and use and engages new consumers using price incentives and advertising strategies likely to appeal to price-sensitive consumers and other vulnerable populations.Substantial use of youth-appealing elements in ENDS ads contradict the tobacco industry's mandate to not appeal to youth, warranting highlighting the gaps in current regulations that allows them to continue appealing to this population.

Health Care Professionals' Clinical Skills to Address Vaping and e-Cigarette Use by Patients: Needs and Interest Questionnaire Study

BACKGROUND

Widespread vaping and e-cigarette use is a relatively new phenomenon. Youth vaping peaked in 2019, with over 25% of high school students currently vaping. e-Cigarettes are used where smoking is not permitted or as an alternative smoking cessation treatment instead of Food and Drug Administration-approved options. Vaping and e-cigarette use has the potential to harm health, including causing adverse respiratory effects and nicotine addiction. Health care professionals need skills training to help their patients with this relatively new and evolving health problem.

OBJECTIVE

The aim of this study is to understand health care professionals' training needs in this subject area to determine the focus for web-based continuing education training.

METHODS

We reviewed the literature on clinical aspects of vaping and e-cigarette use. Using the results and our experience in substance use continuing education, we created a list of key clinical skills and surveyed health care professionals about their training needs. We also asked about their interest in a list of related topics. We recruited individuals who completed our web-based courses on substance use, members of health care professional-related groups, and experts who had published an article on the subject. Half of the 31 health care professionals who completed the survey were physicians and the remainder were primarily nurses, social workers, and counselors. Participants self-identified as nonexperts (n=25) and experts (n=6) on vaping.

RESULTS

Participants who were nonexperts on average agreed or strongly agreed that they needed training in each of 8 clinical skills (n=25; range 3.7-4.4 agreement out of 5). The top two skills were recommending treatments for patients (4.4 out of 5, SD 0.49) and evaluating and treating the health effects of vaping and e-cigarette use (4.4 out of 5, SD 0.50). Experts agreed on the importance of training for health care professionals in all skills but rated the need for training higher than nonexperts for each topic. Over half of the participating health care professionals (44%-80%) were interested in nearly all (9/10, 90%) vaping-related topics on a checklist. The topics participants were most interested in were the pros and cons of vaping versus smoking and the health effects of second- and third-hand vaping. Primary care physicians showed more interest in vaping-related topics than nonprimary care physicians (t13=2.17; P=.02).

CONCLUSIONS

This study confirmed gaps in health care professionals' vaping-related clinical skills identified in the literature by identifying a perceived need for training in related skills and health care professionals' interest in key topics related to vaping prevention and cessation. This study provides specific guidance on which clinical skills training is most needed and which topics are most interesting to health care professionals.

E-cigarette school policy and staff training: Knowledge and school policy experiences with e-cigarette products among a national sample of US middle and high school staff

Background

As youth e-cigarette use has surged in the last several years, teachers and school administrators have reported challenges addressing student use of emerging e-cigarette products on school property. While federal policy prohibits smoking in U.S. schools that receive federal funding, school e-cigarette bans only exist where states or localities have acted. Little is known about school staff experiences with implementing these relatively new policies; this study examines associations between school e-cigarette policies and trainings on school staff awareness and intervention on student e-cigarette use.

Methods

A national convenience sample of 1,526 U.S. middle- and high-school teachers and administrators was surveyed in November-December 2018. Among respondents who provided their job title and indicated that they worked in a school rather than a district (n = 1,480, response rate = 97.0%), separate logistic regressions examine associations of school policies and policy training with e-cigarette awareness and intervention on student e-cigarette use.

Results

Despite being the most popular e-cigarette at the time, fewer than half (47.5%) of respondents identified an image of a JUUL device as an e-cigarette. However, respondents reporting the presence of e-cigarette policies in their schools had higher odds of recognizing e-cigarettes (OR = 3.85, p<0.01), including photo recognition of JUUL (OR = 1.90, p<0.001). Respondents reporting e-cigarette policies also had higher odds of reporting intervention on student e-cigarette use (communicating with students about e-cigarette avoidance: OR = 2.32, p<0.001; reporting students had been caught using e-cigarettes at school: OR = 1.54, p<0.05). Among respondents reporting a school e-cigarette policy, those trained on the policy had higher odds of JUUL photo recognition (OR = 1.54, p<0.01). Respondents trained on e-cigarette policies also had higher odds of reporting intervention (communicating: OR = 3.89, p<0.001; students caught using e-cigarettes: OR = 2.71, p<0.001).

Conclusions

As new tobacco products enter the market, school policies may be important tools to raise school personnel awareness of and intervention on emerging e-cigarette product use. However, policy adoption alone is not sufficient; policy training may further aid in recognition and intervention upon student use of e-cigarettes at school.

A New Ingenious Enemy: Heat-Not-Burn Products

While cigarette smoking is still a major source of morbidity and mortality, e-cigarette usage is skyrocketing, and the tobacco industry is finding new ways to market nicotine. With updated published research highlighting the dangers of cigarette smoking and now vaping, the industry has been developing new techniques and devices that circumvent this research to hook users on tobacco and nicotine. The FDA allowed Philip Morris International (PMI) to sell their heat not burn tobacco products known as iQOS in 2019. By 2019, 49 countries had permitted the sale of iQOS. This commentary summarizes the recent research on heat not burn cigarettes, also known as heated tobacco products and their effects on public policy. We urge policy makers to consider the research published regarding these new products and prevent the widespread use of these products that will harm public health.

e-Cigarette Cessation: Content Analysis of a Quit Vaping Community on Reddit

Background

e-Cigarette use, also known as vaping, has increased dramatically over the past few years, especially among younger demographics. However, researchers have found that a large number of e-cigarette users want to quit. Little is known about the unique aspects of vaping cessation, which is critical to informing the development of relevant resources and interventions for e-cigarette users who want to quit. Social media forums such as Reddit provide opportunities to understand the experiences of behavior change such as quitting vaping from the perspective of end users.

Objective

This study aims to examine a quit vaping subreddit to understand how e-cigarette users are experiencing and approaching vaping cessation. Specifically, we examine methods used to approach quitting, reasons for quitting, and barriers and facilitators to quitting.

Methods

A total of 1228 posts were collected. The posts were inductively coded to generate categories and subcategories using conventional content analysis. Data were analyzed using the NVivo 12 qualitative data analysis software.

Results

Most users reported a preference for approaching quitting through gradual reduction, particularly through the use of their own devices by tapering the nicotine content. Their reasons for quitting were primarily related to experiencing negative physical consequences associated with vaping, especially in relation to their lungs (eg, tight chest), and tired of feeling stuck to the vape because of nicotine addiction. Top barriers to quitting were related to withdrawal symptoms and intensity of addiction. The top facilitators to quitting were related to using distraction techniques (eg, hobby, gaming, and mindfulness exercises), as well as having a positive mindset.

Conclusions

The findings of this study reveal unique aspects that encompass the process of quitting vaping. These findings have significant implications for both policy and intervention development.

Social Media as a Research Tool (SMaaRT) for Risky Behavior Analytics: Methodological Review

BACKGROUND

Modifiable risky health behaviors, such as tobacco use, excessive alcohol use, being overweight, lack of physical activity, and unhealthy eating habits, are some of the major factors for developing chronic health conditions. Social media platforms have become indispensable means of communication in the digital era. They provide an opportunity for individuals to express themselves, as well as share their health-related concerns with peers and health care providers, with respect to risky behaviors. Such peer interactions can be utilized as valuable data sources to better understand inter-and intrapersonal psychosocial mediators and the mechanisms of social influence that drive behavior change.

OBJECTIVE

The objective of this review is to summarize computational and quantitative techniques facilitating the analysis of data generated through peer interactions pertaining to risky health behaviors on social media platforms.

METHODS

We performed a systematic review of the literature in September 2020 by searching three databases-PubMed, Web of Science, and Scopus-using relevant keywords, such as "social media," "online health communities," "machine learning," "data mining," etc. The reporting of the studies was directed by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Two reviewers independently assessed the eligibility of studies based on the inclusion and exclusion criteria. We extracted the required information from the selected studies.

RESULTS

The initial search returned a total of 1554 studies, and after careful analysis of titles, abstracts, and full texts, a total of 64 studies were included in this review. We extracted the following key characteristics from all of the studies: social media platform used for conducting the study, risky health behavior studied, the number of posts analyzed, study focus, key methodological functions and tools used for data analysis, evaluation metrics used, and summary of the key findings. The most commonly used social media platform was Twitter, followed by Facebook, QuitNet, and Reddit. The most commonly studied risky health behavior was nicotine use, followed by drug or substance abuse and alcohol use. Various supervised and unsupervised machine learning approaches were used for analyzing textual data generated from online peer interactions. Few studies utilized deep learning methods for analyzing textual data as well as image or video data. Social network analysis was also performed, as reported in some studies.

CONCLUSIONS

Our review consolidates the methodological underpinnings for analyzing risky health behaviors and has enhanced our understanding of how social media can be leveraged for nuanced behavioral modeling and representation. The knowledge gained from our review can serve as a foundational component for the development of persuasive health communication and effective behavior modification technologies aimed at the individual and population levels.