Perception of the Food and Drug Administration Electronic Cigarette Flavor Enforcement Policy on Twitter: Observational Study

Public Perceptions and Discussions of the US Food and Drug Administration's JUUL Ban Policy on Twitter: Observational Study

BACKGROUND

On June 23, 2022, the US Food and Drug Administration announced a JUUL ban policy, to ban all vaping and electronic cigarette products sold by Juul Labs.

OBJECTIVE

This study aims to understand public perceptions and discussions of this policy using Twitter (subsequently rebranded as X) data.

METHODS

Using the Twitter streaming application programming interface, 17,007 tweets potentially related to the JUUL ban policy were collected between June 22, 2022, and July 25, 2022. Based on 2600 hand-coded tweets, a deep learning model (RoBERTa) was trained to classify all tweets into propolicy, antipolicy, neutral, and irrelevant categories. A deep learning model (M3 model) was used to estimate basic demographics (such as age and gender) of Twitter users. Furthermore, major topics were identified using latent Dirichlet allocation modeling. A logistic regression model was used to examine the association of different Twitter users with their attitudes toward the policy.

RESULTS

Among 10,480 tweets related to the JUUL ban policy, there were similar proportions of propolicy and antipolicy tweets (n=2777, 26.5% vs n=2666, 25.44%). Major propolicy topics included "JUUL causes youth addition," "market surge of JUUL," and "health effects of JUUL." In contrast, major antipolicy topics included "cigarette should be banned instead of JUUL," "against the irrational policy," and "emotional catharsis." Twitter users older than 29 years were more likely to be propolicy (have a positive attitude toward the JUUL ban policy) than those younger than 29 years.

CONCLUSIONS

Our study showed that the public showed different responses to the JUUL ban policy, which varies depending on the demographic characteristics of Twitter users. Our findings could provide valuable information to the Food and Drug Administration for future electronic cigarette and other tobacco product regulations.

Vaping: Public Health, Social Media, and Toxicity

This viewpoint aims to provide a comprehensive understanding of vaping from various perspectives that contribute to the invention, development, spread, and consequences of e-cigarette products and vaping. Our analysis showed that the specific characteristics of e-cigarette products as well as marketing strategies, especially social media marketing, fostered the spread of vaping and the subsequent effects on human health and toxicity. We analyzed the components of e-cigarette devices and e-liquids, including the latest variants whose impacts were often overlooked. The different forms of nicotine, including salts and freebase nicotine, tobacco-derived nicotine, tobacco-free nicotine, and cooling agents (WS3 and WS23), have brought more choices for vapers along with more ways for e-cigarette manufacturers to advertise false understandings and present a greater threat to vapers' health. Our work emphasized the products of brands that have gained significant influence recently, which are contributing to severe public health issues. On the other hand, we also discussed in detail the toxicity of e-liquid components and proposed a toxicity mechanism. We also noticed that nicotine and other chemicals in e-liquids promote each other's negative effects through the oxidative stress and inflammatory nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) pathway, a mechanism leading to pulmonary symptoms and addiction. The impact of government regulations on the products themselves, including flavor bans or regulations, has been limited. Therefore, we proposed further interventions or harm reduction strategies from a public health perspective.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Public perceptions of the FDA's marketing authorization of Vuse on Twitter/X

Introduction

On October 12, 2021, the FDA issued its first marketing granted orders for Vuse, the e-cigarette product by R.J. Reynolds Vapor Company. The public perceptions and reactions to the FDA's Vuse authorization are prevalent on social media platforms such as Twitter/X. We aim to understand public perceptions of the FDA's Vuse authorization in the US using Twitter/X data.

Methods

Through the Twitter/X streaming API (Application Programming Interface), 3,852 tweets between October 12, 2021, and October 23, 2021, were downloaded using the keyword of Vuse. With the elimination of retweets, irrelevant tweets, and tweets from other countries, the final dataset consisted of 523 relevant tweets from the US. Based on their attitudes toward the FDA authorization on Vuse, these tweets were coded into three major categories: positive, negative, and neutral. These tweets were further manually classified into different categories based on their contents.

Results

There was a large peak on Twitter/X mentioning FDA's Vuse authorization on October 13, 2021, just after the authorization was announced. Of the 523 US tweets related to FDA's Vuse authorization, 6.12% (n=32) were positive, 26.77% (n=140) were negative, and 67.11% (n=351) were neutral. In positive tweets, the dominant subcategory was Cessation Claims (n=18, 56.25%). In negative tweets, the topics Health Risk (n=43, 30.71%), Criticize Authorization (n=42, 30.00%), and Big Tobacco (n=40, 38.57%) were the major topics. News (n=271, 77.21%) was the most prevalent topic among neutral tweets. In addition, tweets with a positive attitude tend to have more likes.

Discussion

Public perceptions and discussions on Twitter/X regarding the FDA's Vuse authorization in the US showed that Twitter/X users were more likely to show a negative than a positive attitude with a major concern about health risks.

A systematic review for the impacts of global approaches to regulating electronic nicotine products

Background

The rapid increase in electronic nicotine product (ENP) use among young people has been a global public health challenge, given the potential harm of ENPs and nicotine dependence. Many countries have recently introduced legislations to regulate ENPs, but the impacts of these policies are poorly understood. This systematic review aims to critically synthesise empirical studies on the effects of global regulations regarding ENPs on the prevalence of use, health outcomes and their determinants, using the 4A marketing mix framework (acceptability, affordability, accessibility and awareness).

Methods

Following the PRISMA guideline, we searched PubMed, Embase, Scopus, Web of Science, Academic Search Complete, Business Source Complete, and APA PsycINFO databases from inception until June 14, 2022 and performed citation searches on the included studies. Reviewed literature was restricted to peer-reviewed, English-language articles. We included all pre-post and quasi-experimental studies that evaluated the impacts of e-cigarette policies on the prevalence of ENP use and other health outcomes. A modified Joanna Briggs Institute (JBI) Critical Appraisal checklist for quasi-experimental studies was used for quality assessment. Due to heterogeneity of the included studies, we conducted a narrative synthesis of evidence.

Results

Of 3991 unduplicated records screened, 48 (1.2%) met the inclusion criteria, most were from high-income countries in North America and Europe and 26 studies measured self-reported ENPs use. Flavour restrictions significantly decreased youth ENP use and taxation reduced adult use; mixed results were found for the impacts of age restrictions. Indoor vaping restrictions and the European Tobacco Products Directive (TPD) did not seem to reduce ENP use based on existing studies. Changes in determinants such as sales and perceptions corroborated our conclusions. Few studies assessed the impacts of other regulations such as advertising restrictions and retail licensing requirements.

Conclusions

Flavour restrictions and taxes have the strongest evidence to support effective control of ENPs, while others need powerful enforcement and meaningful penalties to ensure their effectiveness. Future research should focus on under-examined policies and differential impacts across sociodemographic characteristics and countries.

Registration

PROSPERO CRD42022337361.

Comprehensive review of the national surveys that assess E-cigarette use domains among youth and adults in the United States

Surveillance of e-cigarette use among different population groups is important for the timely implementation and evaluation of tobacco regulatory policies. In this review, we identified 13 nationally representative, repeatedly conducted epidemiologic surveys that assess e-cigarette use among U.S. youth and/or adults and have been instrumental in e-cigarette surveillance. These surveys included National Youth Tobacco Survey, Youth Risk Behavior Surveillance System, Monitoring the Future Survey, International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Survey, Behavioral Risk Factor Surveillance System, National Health Interview Survey, Tobacco Use Supplement of the Current Population Survey, Health Information National Trends Survey, Tobacco Products and Risk Perception Surveys, ITC Four Country Smoking and Vaping Survey, National Health and Nutrition Examination Survey, National Survey on Drug Use and Health, and Population Assessment of Tobacco and Health. These surveys vary in scope and detail, with their unique strengths and the regulatory questions that can be answered using each survey data. We also highlighted the gaps in these surveys and made recommendations for improvement.

Public Perceptions of the Food and Drug Administration's Proposed Rules Prohibiting Menthol Cigarettes on Twitter: Observational Study

BACKGROUND

On April 28, 2022, the Food and Drug Administration (FDA) proposed rules that prohibited all menthol-flavored cigarettes and other flavored cigars to prevent the initiation of tobacco use in youth and reduce tobacco-related diseases and death.

OBJECTIVE

The objective of this study was to investigate public perceptions of the FDA's proposed menthol cigarette rules on Twitter.

METHODS

Through the Twitter streaming application programming interface, tobacco-related tweets were collected between April 28, 2022, and May 27, 2022, using a set of keywords, such as smoking, cigarette, and nicotine. Furthermore, 1941 tweets related to the FDA's proposed menthol cigarette rules were extracted. Based on 300 randomly selected example tweets, the codebook for the attitudes toward the FDA's proposed rules and related topics was developed by 2 researchers and was used to label the rest of the tweets.

RESULTS

Among tweets related to the FDA's proposed menthol cigarette rules, 536 (27.61%) showed a positive attitude, 443 (22.82%) had a negative attitude, and 962 (49.56%) had a neutral attitude toward the proposed rules. Social justice (210/536, 39%) and health issues (117/536, 22%) were two major topics in tweets with a positive attitude. For tweets with a negative attitude, alternative tobacco or nicotine products (127/443, 29%) and racial discrimination (84/536, 16%) were two of the most popular topics.

CONCLUSIONS

In general, the public had a positive attitude toward the FDA's proposed menthol cigarette rules. Our study provides important information to the FDA on the public perceptions of the proposed menthol cigarette rules, which will be helpful for future FDA regulations on menthol cigarettes.

Public Perceptions on the Policy of Electronic Cigarettes as Medical Products on Twitter

Starting from 1 October 2021, Australia requires a prescription for purchasing nicotine vaping products. On 29 October 2021, the UK provided a guideline to treat e-cigarettes as medical products. This study aims to understand public perceptions of the prescription policy in Australia and the UK on Twitter. Tweets related to e-cigarettes from 20 September 2021 to 31 December 2021 were collected through Twitter streaming API. We adopted both a human and machine learning model to identify a total of 1795 tweets from the UK and Australia related to the prescription policy. We classified them into pro-policy, anti-policy, and neutral-to-policy groups, and further characterized tweets into different topics. Compared to Australia, the proportion of pro-policy tweets in the UK was significantly higher (19.43% vs. 10.92%, p < 0.001), while the proportion of anti-policy tweets was significantly lower (43.4% vs. 50.09%, p = 0.003). The main topics for different attitudes towards the prescription policy between the two countries showed some significant differences, for example, "help quit smoking" in the UK and "health effect of e-cigarettes" in Australia for the positive attitude, "economic effect" in the UK and "preventing smoking cessation" in Australia for the negative attitude, which reflected different public concerns. The findings might provide valuable guidance for other countries to implement a similar policy in the future.

Potential Impact of FDA Flavor Enforcement Policy on Vaping Behavior on Twitter

In January 2020, the FDA announced an electronic cigarette (e-cigarette) flavor enforcement policy to restrict the sale of all unauthorized cartridge-based flavored e-cigarettes except tobacco and menthol flavors, which was implemented on 6 February 2020. This study aimed to understand the potential influence of this policy on one vaping behavior change-quitting vaping-using Twitter data. Twitter posts (tweets) related to e-cigarettes were collected between June 2019 and October 2020 through a Twitter streaming API. Based on the geolocation and keywords related to quitting vaping, tweets mentioning quitting vaping from the US were filtered. The demographics (age and gender) of Twitter users who mentioned quitting vaping were further inferred using a deep learning algorithm (deepFace). The proportion of tweets and Twitter users mentioning quitting vaping were compared between before and after the announcement and implementation of the flavor policy. Compared to before the FDA flavor policy, the proportion of tweets (from 0.11% to 0.20% and 0.24%) and Twitter users (from 0.15% to 0.70% and 0.86%) mentioning quitting vaping were significantly higher after the announcement and implementation of the policy (p-value < 0.001). In addition, there was an increasing trend in the proportion of female and young adults (18-35 years old) mentioning quitting vaping on Twitter after the announcement and implementation of the policy compared to that before the policy. Our results showed that the FDA flavor enforcement policy did have a positive impact on quitting vaping on Twitter. Our study provides an initial evaluation of the potential influence of the FDA flavor enforcement policy on user vaping behavior.

The reciprocal relationships of social norms and risk perceptions to cigarette, e-cigarette, and cannabis use: Cross-lagged panel analyses among US young adults in a longitudinal study

INTRODUCTION

Given the distinct and evolving social norms, research on health implications, and regulations regarding cigarettes, e-cigarettes, and cannabis, it is important to understand the interplay between social norms, risk perceptions, and use of these products.

METHODS

We analyzed 3 waves of longitudinal data (Fall 2018, 2019, 2020) from 3006 young adults (Mage=24.56, 54.8% female, 31.6% sexual minority, 39.6% racial/ethnic minority) from 6 US metropolitan statistical areas. Cross-lagged panel models (CLPMs) examined reciprocal relationships of (a) perceived social norms (i.e., peer use, social acceptability) and risk perceptions (i.e., harm, addictiveness) to (b) number of days of cigarette, e-cigarette, and cannabis use in the past 30 days, respectively.

RESULTS

At baseline, lifetime and past 30-day use prevalence was: 61.8% and 26.9% for cigarettes, 57.7% and 37.7% for e-cigarettes, and 70.7% and 39.2% for cannabis. Perceived social norms and use of cigarettes and e-cigarettes decreased over time, and risk perceptions increased (except cigarettes showed stable perceived harm). Regarding cannabis, perceived social norms and use increased, yet perceived harm and addictiveness also increased. CLPM indicated that greater perceived social norms predicted greater cigarette, e-cigarette, and cannabis use over time, and vice versa. While greater perceived risk predicted less e-cigarette and cannabis use and vice versa, this did not hold true for cigarettes: use predicted lower perceived risk, but risk perceptions did not predict later use.

CONCLUSIONS

Tobacco and cannabis intervention and regulatory efforts should address health risks of use, particularly of e-cigarettes and cannabis, as well as denormalizing use.

The role of synthetic coolants, WS-3 and WS-23, in modulating E-cigarette-induced reactive oxygen species (ROS) in lung epithelial cells

There has been a substantial rise in e-cigarette (e-cig) use or vaping in the past decade, prompting growing concerns about their adverse health effects. Recently, e-cig manufacturers have been using synthetic cooling agents, like WS-23 and WS-3, to provide a cooling sensation without the "menthol taste". Studies have shown that aerosols/vapes generated by e-cigs can contain significant levels of reactive oxygen species (ROS). However, studies investigating the role of synthetic coolants in modulating ROS levels generated by e-cigs are lacking. This study seeks to understand how synthetic coolants, e-cig additives that have become increasingly prevalent in e-liquids sold in the United States (US), impact acellular ROS production from e-liquid aerosols as well as cellular ROS levels from pulmonary epithelial cells exposed to these e-liquids. To further explain, our study aims to understand whether the addition of WS-3 and WS-23 to e-liquid base and e-liquid base with nicotine significantly modifies generated acellular ROS levels within aerosolized e-liquids, as well as cellular ROS within BEAS-2B cells treated with these same e-liquids. Aerosols were generated from e-liquids with and without synthetic coolants through a single-puff aerosol generator; subsequently, acellular ROS was semi-quantified in H2O2 equivalents via fluorescence spectroscopy. Our acellular ROS data suggest that adding WS-3 to e-liquid base (PG:VG), regardless of nicotine content, has a minimal impact on modifying e-cig generated acellular ROS levels. Additionally, we also measured cellular ROS in lung epithelial cells using both e-liquids containing and not containing synthetic coolants via the CellROX Green fluorescent sensor. Similar comparable results were found in BEAS2B cells though ROS was increased by WS-3 and WS-23 treated in e-cig nicotine groups. Altogether, our data suggest that neither the addition of WS-23 nor WS-3 to e-liquid base solution, with and without nicotine, significantly modifies e-cig generated acellular ROS levels within aerosolized e-liquids and cellular ROS levels within treated BEAS-2B cells. Together, our data provide insight into whether synthetic coolants added to e-liquids could impact vaping-induced oxidative stress in the lungs.

Perceptions of Oral Nicotine Pouches on Reddit: Observational Study (Preprint)

Background

Oral nicotine pouches are a new form of tobacco-free nicotine products launched in recent years with a variety of flavors.

Objective

This study aims to examine the public perceptions and discussions of oral nicotine pouches on Reddit, a popular social media platform for sharing user experiences.

Methods

Between February 15, 2019, and February 12, 2021, a total of 2410 Reddit posts related to oral nicotine pouches were obtained over a 2-year period. After the removal of unrelated or commercial posts, 653 Reddit posts related to oral nicotine pouches remained. Topics and sentiments related to oral nicotine pouches on Reddit were hand coded.

Results

The number of Reddit posts related to oral nicotine pouches increased during the study period. Content analysis showed that the most popular topic was “sharing product information and user experience” (366/653, 56%), in which sharing oral nicotine pouch products and user experiences were dominant. The next popular topic was “asking product-related questions” (product properties and product recommendations; 115/653, 17.6%), followed by “quitting nicotine products” such as vaping or smoking through use of oral nicotine pouches or quitting the oral nicotine pouches themselves (83/653, 12.7%) and “discussing oral nicotine pouch–related health” symptoms or concerns related to oral nicotine pouches (74/653, 11.3%). The least popular topic was “legality and permissions” related to oral nicotine pouches (15/653, 2.3%). In addition, a greater number of Reddit posts described positive attitudes compared to negative attitudes toward oral nicotine pouches (354/653, 54.2% vs 101/653, 15.5%; P<.001).

Conclusions

Reddit posts overall had a positive attitude toward oral nicotine pouches and users were actively sharing product and user experiences. Our study provides the first insight on up-to-date oral nicotine pouch discussions on social media.

Investigating the Impact of New York State Flavor Ban on E-cigarettes Discussion on Twitter: Observational Study (Preprint)

Background

On May 18, 2020, the New York State Department of Health implemented a statewide flavor ban to prohibit the sales of all flavored vapor products, except for tobacco or any other authorized flavor.

Objective

This study aims to investigate the discussion changes in e-cigarette–related tweets over time with the implementation of the New York State flavor ban.

Methods

Through the Twitter streaming application programming interface, 59,883 e-cigarette–related tweets were collected within the New York State from February 6, 2020, to May 17, 2020 (period 1, before the implementation of the flavor ban), May 18, 2020-June 30, 2020 (period 2, between the implementation of the flavor ban and the online sales ban), July 1, 2020-September 15, 2020 (period 3, the short term after the online sales ban), and September 16, 2020-November 30, 2020 (period 4, the long term after the online sales ban). Sentiment analysis and topic modeling were conducted to investigate the changes in public attitudes and discussions in e-cigarette–related tweets. The popularity of different e-cigarette flavor categories was compared before and after the implementation of the New York State flavor ban.

Results

Our results showed that the proportion of e-cigarette–related tweets with negative sentiment significantly decreased (4305/13,246, 32.5% vs 3855/14,455, 26.67%, P<.001), and tweets with positive sentiment significantly increased (5246/13,246, 39.6% vs 7038/14,455, 48.69%, P<.001) in period 4 compared to period 3. “Teens and nicotine products” was the most frequently discussed e-cigarette–related topic in the negative tweets. In contrast, “nicotine products and quitting” was more prevalent in positive tweets. The proportion of tweets mentioning mint and menthol flavors significantly increased right after the flavor ban and decreased to lower levels over time. The proportions of fruit and sweet flavors were most frequently mentioned in period 1, decreased in period 2, and dominated again in period 4.

Conclusions

The proportion of e-cigarette–related tweets with different attitudes and frequently discussed flavor categories changed over time after the implementation of the New York State ban of flavored vaping products. This change indicated a potential impact of the flavor ban on public discussions of flavored e-cigarettes.