Exposure and Engagement With Tobacco- and E-Cigarette-Related Social Media

Exposure to user-generated e-cigarette content on social media associated with greater vulnerability to e-cigarette use among youth non-users

INTRODUCTION

Social media are important venues for youth's exposure to e-cigarette content. This study examined how exposure to user-generated e-cigarette content (i.e., content created and shared by individual social media users) is associated with vulnerabilities to e-cigarette use among youth non-users.

METHODS

We pooled data from the 2021 and 2022 National Youth Tobacco Survey. Youth who have never used e-cigarettes were included. Weighted linear and logistic regressions were conducted to examine how exposure to user-generated e-cigarette content (from real-life friends, online-only friends, and celebrities/influencers) on social media was associated with e-cigarette use vulnerabilities measured by perceived norms, perceived risk, and susceptibility of use, controlling for demographics, advertising exposure, and mental health conditions. Multiple imputations were performed to account for missing data.

RESULTS

Exposure to e-cigarette content on social media posted by real-life friends, online-only friends, and celebrities/influencers were associated with more positive descriptive norm (βs = 1.56, 0.37, and 0.35, respectively, all ps < .001), more positive injunctive norm (βs = 0.46, 0.19, and 0.10, respectively, all ps < .001), and higher odds of e-cigarette use susceptibility (ORs = 1.48, 1.50. 1.29, respectively, all ps < .001). Exposure to content posted by real-life and online-only friends were associated with reduced risk perception of e-cigarette use (β = -0.04, p < 0.05 and β = -0.07, p < 0.001).

CONCLUSIONS

Our study highlighted that friends and celebrities/influencers are important sources on social media that can influence youth non-users' vulnerabilities to e-cigarette use. Interventional messages communicated through friends and influencers on social media may in turn help reduce e-cigarette vulnerability among youth non-users.

Sources of exposure to non-tobacco nicotine electronic nicotine delivery systems and associations with susceptibility to use and use behaviors among young adults in the United States

INTRODUCTION

The Electronic Nicotine Delivery Systems (ENDS) industry recently introduced non-tobacco nicotine (NTN), which is not tobacco-derived and is often marketed as "tobacco-free nicotine." Given its novelty, it is important to understand where young adults learn about NTN ENDS. This study examined sources of exposure to NTN ENDS and relationships with NTN ENDS use and susceptibility.

METHODS

We analyzed online survey data collected in Fall 2021 from 642 young adults (18-25 years) who had heard of NTN ENDS. We assessed 9 sources of NTN ENDS exposure (e.g., retail stores, social media) and examined associations between sources of exposure and NTN current (past-month) use, lifetime (non-current) use, and susceptibility to use, adjusting for demographics and other tobacco product use.

RESULTS

Participants reported current NTN ENDS use (37.4%), lifetime use (12.0%), susceptibility (18.5%), or no susceptibility to use (32.1%). The most common sources of NTN ENDS exposure were retail stores (87.7%) and social media (81.0%). Exposure to NTN ENDS via social media was associated with greater odds of current NTN ENDS use (vs. no susceptibility) (aOR = 1.83, 95%CI: 1.02-3.28). Exposure via online streaming platforms was associated with greater odds of current (aOR = 1.75, 95%CI: 1.08-2.82) and lifetime NTN ENDS use (aOR = 2.42, 95%CI: 1.25-4.68).

CONCLUSIONS

Young adults were exposed to and learned about NTN ENDS from diverse sources, primarily retail shops and social media. Further, exposure via social media and streaming platforms were associated with NTN ENDS use. Future studies should explore the content of NTN information from various sources to inform prevention efforts.

Young Adults' Exposure to and Engagement With Tobacco-Related Social Media Content and Subsequent Tobacco Use

INTRODUCTION

Nicotine/tobacco social media content may increase young people's risk for use. This study examined prospective associations between exposure to and engagement with nicotine/tobacco-related social media content and nicotine/tobacco use among young adults.

AIMS AND METHODS

Young adults (N = 2080) originally recruited from Southern California high schools for a prospective cohort study reported frequency of viewing and posting nicotine/tobacco content on four social media platforms (Facebook, Instagram, Twitter, and YouTube). Participants also reported frequency of seeing nicotine/tobacco posts from friends, seeing nicotine/tobacco posts from influencers or celebrities, and liking nicotine/tobacco posts. Within subsamples of nicotine/tobacco never users (n = 794), past users (n = 897) and current users (n = 389), analyses examined associations of baseline (May-October 2020) social media content exposure and engagement with follow-up (January-June 2021) tobacco use initiation (among never users), resumption (among past users), and continuation (among current users), adjusting for sociodemographic and socioenvironmental characteristics.

RESULTS

Never users who saw nicotine/tobacco posts from friends (Adjusted Odds Ratio [AOR] = 2.91 [95% Confidence Interval [CI]: 1.46, 5.82], p = .002) or from celebrities or influencers (AOR = 2.77 [1.32, 5.84], p = .007) were significantly more likely to initiate nicotine/tobacco use than their peers. Among past users, posting nicotine/tobacco content at baseline was associated with use resumption (AOR = 1.77 [1.12, 2.80], p = .014). Content exposure and engagement were not associated with nicotine/tobacco use continuation among current users (p-values > .05).

CONCLUSIONS

Seeing nicotine/tobacco posts from friends, influencers, or celebrities was associated with greater odds of tobacco use initiation, but not resumption or continuation, 6 months later. Young adults with past nicotine/tobacco use who post about nicotine/tobacco may be at elevated risk for resuming use.

IMPLICATIONS

Young adults with exposure to nicotine/tobacco social media content were more likely than their peers to initiate nicotine/tobacco use 6 months later. Past nicotine/tobacco users who reported posting about nicotine/tobacco on social media at baseline were more likely than their peers to resume nicotine/tobacco use. Among young adults with current nicotine/tobacco use at baseline, social media activity did not predict odds of nicotine/tobacco use continuation at follow-up. Nicotine/tobacco content on social media should be restricted to reduce young people's chances of nicotine/tobacco use initiation or resumption.

Changes in smoking patterns and characteristics of Koreans using the Korea National Health and Nutrition Examination Survey 2013-2021 data

OBJECTIVES

This study explored factors related to Korean adults' smoking patterns and also the reasons for using new types of tobacco products.

STUDY DESIGN

Cross-sectional survey.

METHODS

Data from the Korea National Health and Nutrition Examination Survey from 2013 to 2021 were used. The prevalence of the use of electronic cigarettes (e-cigarettes) or heated tobacco products (HTPs) alone or in combination with conventional cigarettes (CC) and the reasons for using new tobacco products are presented. Factors associated with using new types of tobacco products alone or in combination with CC compared to exclusive CC users were identified using multinomial logistic regression analysis.

RESULTS

The prevalence of current smoking was 25.54% in 2013 and 23.05% in 2021, with no significant change. The prevalence of CC decreased from 23.39% in 2013 to 15.77% in 2021. The prevalence of new tobacco use in combination with CC did not show a definite trend. The prevalence of exclusive use of new tobacco was <1% until 2018 and has rapidly increased thereafter. Of the HTPs users, 46.68% responded with 'no cigarette smell' as the main reason for HTPs use, followed by 'It seems less harmful than cigarette' (19.19%), and 'It seems to be helpful for quitting smoking' (15.04%). Of the e-cigarette users, 45.19% responded 'It seems to be helpful for quitting smoking' as the main reason for e-cigarette use, followed by 'It is less harmful than cigarettes' (19.98%). Compared to CC users, new tobacco users were younger, had a higher household income or education, and used more nutritional supplements.

CONCLUSION

Regulations for newer tobacco products are more lenient than for traditional cigarettes, leading to misunderstandings, especially among women and young people. To increase awareness of the risks of these products, specific policies such as disclosure of ingredients, ban on online sales, and increase in consumption tax, are needed.

Use of Brand Engagement Appeals in US Cigarette and E-Cigarettes Ads (2019-2020)

Background: The tobacco industry has historically used brand engagement - communication tactics companies use to increase customer attachment to a brand and brand loyalty - to recruit and retain consumers. Limited information is available to assess the brand engagement tactics used to promote the two most popular tobacco products in the US - cigarettes and electronic cigarettes (e-cigarettes) - across different advertising platforms (e.g., direct-to-consumer (DTC), social media). Material and methods: We acquired 520 cigarette and 5,502 e-cigarette ads that ran in the US January 2019 to December 2020 from market research firms (Kantar, Numerator), Rutger's University ad surveillance website (trinketsandtrash.org), and branded social media accounts. Ads were double-coded for eight types of brand engagement tactics: Price Promotion, Sweepstakes, Mobile App, Email/Mail List, Free Gift, Social Media engagement request, Sponsored Events, and Auto-Ship subscription program. We report presence of brand engagement tactics by product type and advertising platform. Results: Overall, 62.9% of cigarette ads and 49.9% of e-cigarette ads contained at least one brand engagement tactic. For cigarette ads, the most common tactics were Sweepstakes and Mobile App requests, which were most commonly featured in DTC ads. For e-cigarettes, the most common tactic was Price Promotion which was featured in most DTC and online e-cigarette ads. Conclusions: Brand engagement was common in this sample of cigarette and e-cigarette ads. Our findings highlight key differences in the type of brand engagement tactic used to promote each product on different advertising platforms. Results can inform continued advertising surveillance studies and regulatory efforts.

Characteristics of Cheyenne little filtered cigar Instagram ads, 2019-2020

INTRODUCTION

Little is known about little filtered cigar (LFC) marketing on social media. We examined the characteristics of Instagram posts by Cheyenne-a popular LFC brand-from 2019 to 2020.

METHODS

We conducted a content analysis of 323 images posted in 2019 and 2020. Descriptive statistics were examined, and χ2 and Fisher's exact tests were used to test differences by year.

RESULTS

Most posts (76.0%) showed ≥1 pack and/or LFC stick, which look highly similar to cigarette packs and sticks. The pack was often flavoured (62.2%). Images of lit LFC sticks increased from 2019 (12.2%) to 2020 (26.7%, p=0.005). Warning labels were present on the ad in 79.9% of posts, but always at the bottom, and used the same single warning statement that they are not a safe alternative to cigarettes. The depiction of people nearly doubled from 2019 (18.1%) to 2020 (34.8%, p=0.001), and women (50.6%) were more commonly depicted than men (32.1%). Popular depictions and themes included the outdoors (57.6%) and seasonal imagery (36.2%) among others.

DISCUSSION

Cheyenne actively used Instagram to market its product and grow its brand. Posts seemed designed to promote the similarity of their LFC to cigarettes, through depictions of cig-a-like packs/sticks. Although warning labels were prevalent on Cheyenne Instagram posts, the warnings were not compliant with FDA warning guidelines and might have been counterproductive by emphasising their viability as cigarette alternatives rather than their dangerous health effects. Future surveillance is needed, and regulation of LFC advertising on social media may be warranted.

Viral Vaping: A systematic review and meta analysis of e-cigarette and Tobacco-Related social media content and its influence on youth behaviours and attitudes

AIMS

E-cigarette and tobacco-related content on social media continues to rise from lax restrictions on both personal and promotional posts. This content has been linked to various mechanisms of increased e-cigarette and tobacco use (i.e., lower risk perceptions and increased susceptibility). This study aimed to synthesis the association between exposure to e-cigarette and tobacco-related content and youth behaviours and attitudes.

METHODS

A comprehensive search was conducted on PubMed, Scopus, PsycINFO and Web of Science. Studies published post-2004 reporting effect estimates for exposure or engagement with e-cigarette or tobacco content on social media and behaviour or attitude outcomes were included.

RESULTS

Thirty-two studies (N = 274,283, aged 9 to 25 years) were included for synthesis. Meta-analyses revealed significant associations between engagement with tobacco content and use (OR 2.21; 95% CI = 1.27-3.82, p =.005; I2 = 96.4%), exposure to tobacco content and never users' lower risk perceptions (OR 0.68; 95% CI = 0.49-0.91; p =.011; I2 = 78.2%), and exposure to e-cigarette content and use (OR 1.37; 95% CI = 0.99-1.88; p = 0.058; I2 = 64.4%). There was no observed relationship between exposure to tobacco content and ever users' risk perceptions (OR 0.83; 95% CI = 0.61-1.13; p =.231; I2 = 83.5%). Qualitative synthesis found significant associations between tobacco exposure and increased current use and pro-tobacco attitudes; e-cigarette exposure and increased susceptibility and lower risk perceptions; tobacco engagement and increased susceptibility; e-cigarette engagement and increased use; dual exposure and increased susceptibility; and dual engagement and increased dual use. Mixed findings were identified for the influence of e-cigarette exposure on attitudes, tobacco exposure on susceptibility, dual exposure on dual use behaviours, and dual engagement on dual susceptibility.

CONCLUSIONS

Findings suggest an association between exposure and engagement to e-cigarette or tobacco products on social media and use or pro-use attitudes among youth. Further substantive research in the area of youth-specific use and attitudes following exposure and engagement with e-cigarette and tobacco content is needed to quantify this association.

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.

Developing a theoretical marketing framework to analyse JUUL and compatible e-cigarette product promotion on Instagram

BACKGROUND

E-cigarette promotion on social media coincided with the rapid growth of e-cigarette use among American youth, particularly with the increased JUUL pod vaporiser use. We examined commercial JUUL-related messages on Instagram to identify marketing appeals used to target users along the continuum of e-cigarette use; we mapped the appeals to existing theoretical marketing frameworks to better understand industry strategies.

METHODS

Hashtag-based keyword rules were used to collect JUUL-related posts from the Instagram application programming interface, 1 March-13 November 2018. Posts were classified as commercial or non-commercial. A combination of machine learning methods, keyword algorithms and human coding were used to characterise message themes in commercial posts.

RESULTS

Keyword filters captured 50 817 relevant posts and 41% were commercial. Among commercial posts, 91% contained recruitment/trial-based appeals (eg, combustible tobacco cessation; product sampling; giveaways) and 71% featured reinforcement/addiction-related appeals (eg, loyalty programmes). None of the commercial messages contained e-cigarette cessation-related appeals and less than 25% mentioned quitting combustible tobacco as a recruitment appeal.

CONCLUSIONS

Instagram posts featuring e-cigarette related marketing can increase exposure to persuasive messages encouraging e-cigarette trial and use particularly among susceptible youth. Stronger regulations are needed to prevent exposure to social media marketing among young social media users.

Tobacco advertising exposure and product use among young adults: An ecological momentary assessment approach

INTRODUCTION

Tobacco-related content is prevalent on social media, yet many methods of measuring exposure are inadequate due to the personalized nature of online marketing. The purpose of this paper is to examine the association between exposure to pro-tobacco messages (both industry-sponsored and user-generated) and the use of tobacco products, as reported via ecological momentary assessment (EMA).

METHODS

Young adults (n = 175) were instructed to record all sightings of marketing (both in-person and online) related to tobacco for 28 days. Tobacco product use and recall of message encounters were assessed daily using app-initiated EMA.

RESULTS

Participants who reported exposure to tobacco messages were significantly more likely to report using tobacco, adjusting for gender, age, race/ethnicity, baseline use of any tobacco product, and having friends who use tobacco and e-cigarettes (p <.001). For each industry-sponsored message viewed, the odds of using tobacco or e-cigarettes in a given day increased by a factor of 1.77 (95 % CI = 1.41, 2.23). For each user-generated message viewed, the odds of using tobacco or e-cigarettes in a given day increased by a factor of 1.52 (95 % CI = 1.27, 1.83).

DISCUSSION

To our knowledge, this is the first study to specifically examine the association between exposure to user-generated messages and daily tobacco use. The findings suggests that there is a unique element to user-generated messages that distinguishes them from both traditional marketing and from simple peer influence.

User-generated content and influencer marketing involving e-cigarettes on social media: a scoping review and content analysis of YouTube and Instagram

BACKGROUND

Evidence suggests that experimentation with e-cigarettes among young people is increasing. Social media is widely used by young people with user-generated content and influencer marketing particularly influential in promoting products. This paper documents a snapshot of online user-generated content and influencer marketing related to e-cigarettes on YouTube and Instagram.

METHODS

Scoping review of relevant e-cigarette-related content on two social media platforms popular with youths, YouTube and Instagram, between June and August 2021. Content analysis was undertaken to examine text, audio, and video content, recording age restrictions, health warnings, page characteristics, and post characteristics. Narrative post content was coded using a coding frame that was developed inductively in response to emergent categories.

RESULTS

Vaping was portrayed positively on social media; of the posts analysed, 86.5% (n = 90 of 104) of Instagram posts and 66.0% (n = 64 of 97) of YouTube videos. Warnings about age restrictions and health (e.g., nicotine addiction/toxicity) did not feature in the majority of posts; 43.3% (n = 42) of YouTube videos (n = 42) contained an age warning compared to 20.2% of Instagram posts (n = 21). While 25.8% (n = 25) of YouTube videos and 21.2% of Instagram (n = 22) posts contained a health warning.

CONCLUSION

Of concern is the fact that the vast majority of YouTube and Instagram content about e-cigarettes promoted their use, and typically the content does not contain age and/or health warnings. These findings may highlight a priority for governmental policy to restrict the ability of marketers to reach youths with social media content promoting e-cigarettes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Examining influencer compliance with advertising regulations in branded vaping content on Instagram

Background

Youth and young adults are exposed to vaping advertisements on social media sites, despite regulations and guidelines intended to reduce the prevalence of such content on these platforms. This research uses replicable criteria to identify vaping influencers who have worked with vaping brands to promote vaping products on Instagram and documents the extent to which posts by these users comply with existing advertising regulations.

Methodology

We conducted three google searches collecting eight different vaping influencer lists, with a total of 575 unique influencers. We limited our sample to public accounts with 100,000 followers or more (n = 54). An initial sample of 360 Instagram posts was used to identify an analytic sample of 262 vape-related posts from 2021. We conducted a conceptual content analysis to first identify unambiguous vaping advertisements (branded content), and then code ads for compliance with existing regulations.

Results

On average, the 54 Instagram accounts had 265,851.9 followers (sd = 383,349.8) and 4,158 posts (sd = 7,302.1). Most posts featured vaping products 239 (91.2%), with 186 (76.2%) posts being unambiguously branded vape advertisements and 31 (14.3%) even including purchase links in the post itself. However, one post complied with FTC disclosure guidelines. Although 50 (20.9%) had warning labels, only 8 (15.1%) were fully compliant with FDA warning label guidelines.

Discussion

Findings demonstrate minimal compliance with existing regulations among influencers known to have financial relationships with vaping brands. Most influencer posts are unambiguous, branded, vaping advertisements. Implications for barriers to regulating influencer content and the need for greater enforcement resources are discussed.

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

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

An examination of the social perceptions and vaping preferences of young electronic nicotine delivery system users

Background

Little research has been conducted on social aspects and preferences of electronic nicotine delivery system (ENDS) use among young ENDS users, and none have examined differences in these aspects and preferences by gender and tobacco use status.

Methods

A total of 558 young regular vapers (ages 16-24; vaped at least once a week for the last 3 months) from Nova Scotia were recruited to complete a demographic and vaping questionnaire. A 2 x 3 study design was used to compare participants on social aspects and vaping preferences based on gender (male or female) and tobacco use status (never, former, or current smoker). Chi-square tests were used to determine significant differences, and Bonferroni tests were used to assess over- and under-representation within significant variables.

Results

Current tobacco-using male vapers had a higher frequency of experiencing pressure to vape from friends and current employment as compared to females. Former and never tobacco-using male vapers had a higher frequency of parental awareness of their vaping behavior than females. Former tobacco-using female vapers had a higher frequency of being influenced to vape by others they know on social media than males. Both never and former tobacco-using females reported a higher frequency of exposure to vaping content on social media than males. Never tobacco-using female vapers preferred vape pen devices relative to males.

Conclusions

Important gender differences by tobacco use status exist and demonstrate differential patterns of social influence for ENDS use and their experiences within this demographic.

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

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

Examination of Tobacco-Related Messaging and Tobacco Use over Time among U.S. Military Young Adults

Background: People from minoritized populations have historically been targeted by tobacco companies. Little is known about exposure to tobacco-related messages among military personnel from disadvantaged backgrounds. Objectives: The current study aimed to examine exposure to tobacco-related messaging across many nicotine products and through a variety of mediums (i.e., family, friends, advertisements, event promotions, social media) among diverse military populations and use one year later in a sample of young adults who recently enlisted in the U.S. Air Force. Methods: In this study, 8,901 U.S. Air Force trainees reported on demographics, tobacco use, and exposure to positive tobacco messages from social sources (i.e., friends, family, social media) and environmental sources (i.e., advertisements and promotions). Tobacco use was reported one-year later. Results: Compared to others of the same reported racial/ethnic background, Latino/a/x (Relative Risk Ratio [RRR] = 1.354, 95% CI: [1.145, 1.563]) and multiracial (RRR = 1.594, 95% CI: [1.173, 2.016]) participants who were exposed to positive tobacco messages from social sources were significantly more likely to report tobacco product use at one-year follow-up than those who were not exposed to social messages. Exposure to positive tobacco messages from environmental sources were not significantly associated with tobacco use one year later. Conclusions: Social messages may play an important role in increasing risk of tobacco use among some minoritized populations. Cultural as well as systemic factors could be addressed in future tobacco prevention programs to decrease the potency of positive tobacco-related social messages among Latino/a/x and multiracial communities.

Social environment exposure to electronic cigarettes and its association with e-cigarette use among adolescents in Shanghai, China

Objective

This study investigated adolescents' social-environmental exposure to e-cigarettes in association with e-cigarette use in Shanghai, China. We also explored these differences by gender and school type.

Methods

Sixteen thousand one hundred twenty-three students were included by a stratified random cluster sampling, and the number was weighted according to selection probability. Association between social environment exposure and e-cigarette use was examined by multivariate logistic regressions.

Results

There were 35.07, 63.49, 75.19, 9.44, and 18.99% students exposed to secondhand e-cigarette aerosol (SHA), e-cigarette sales, e-cigarette information, parents' and friends' e-cigarette use. Students exposed to SHA (aOR = 1.73, 95% CI 1.40-2.14), e-cigarette sales from ≥2 sources (aOR = 1.55, 95% CI 1.18-2.03), e-cigarette information exposure from ≥2 sources (aOR = 1.39, 95% CI 1.05-1.83), and having a social e-smoking environment (friends' e-cigarette use: aOR = 2.56, 95% CI 2.07-3.16; parents' e-cigarette use: aOR = 1.54, 95% CI 1.17-2.02) were significantly associated with their intention to use e-cigarettes. More girls were exposed to e-cigarette sales in the malls, e-cigarette information at points of sale and on social media (P < 0.01), and exposure to sales from ≥2 sources were associated with girls' intention to use e-cigarettes (aOR = 1.84, 95% CI 1.22-2.78). However, boys were more likely to be exposed to friends' e-cigarette use (P < 0.001), and having friends using e-cigarettes was associated with greater intention to use them in boys (aOR = 2.64, 95% CI 1.97-3.55). Less vocational high school students were exposed to parents' e-cigarette use (P < 0.001), but they were more likely to use e-cigarettes in the future after being exposed (aOR = 2.27, 95% CI 1.50-3.43). A similar phenomenon was observed between junior high students and their exposure to SHA.

Conclusions

This study reported adolescents' high exposure rates to the social environment of e-cigarettes. Exposure to SHA, e-cigarette sales from ≥2 sources, e-cigarette information from ≥2 sources and having a social e-smoking environment were related to adolescents' intention to use e-cigarettes. Differences in gender and school type were observed. More attention should be paid to girls, and different interventions should be designed for different types of school students. Additionally, comprehensive tobacco control policies are needed.

Industry response to strengthened regulations: amount and themes of flavoured electronic cigarette promotion by product vendors and manufacturers on Instagram

Background

Social media discussion tends to follow news about proposed or enacted government policies. Thus, digital discourse surveillance may be an effective and unobtrusive way of understanding industry and public response to policies and regulations, including in the domain of tobacco control. Recently, the US Food and Drug Administration restricted sales of flavoured cartridge and disposable vape products. Historically, the tobacco industry used modification of product characteristics, labelling or packaging to work around flavour restrictions. We aimed to characterise strategies used by nicotine product manufacturers and vendors to promote flavoured products on Instagram and to identify policy workaround tactics.

Methods

Keyword rules were used to collect flavoured electronic cigarette-related Instagram posts from CrowdTangle, from 1 January 2019 to 31 December 2021. Posts were coded for commercial content and promotional strategies using a combination of machine learning methods, keyword algorithms and human coding. Additional exploratory analyses were conducted to identify major discussion themes. Non-English posts were excluded from the analyses.

Results

Keyword filters captured 113 393 relevant posts from 391 unique accounts, with 46 076 posts referencing flavour promotion (40.6%) and 2124 (2%) posts mentioning alternatives to restricted flavoured products or strategies to evade flavour sales restrictions. Promotional messages featured non-characterising flavour references, ‘off-brand’ product substitutes, promotion of new flavoured product technologies, innovation, do-it-yourself appeals, global promotion, international delivery and encouraged flavoured product stockpiling. In addition, promotion of refillable devices, e-juice, tank systems and ‘box mod’ vaporizers was present.

Conclusion

Social media surveillance can enhance our understanding of public health needs and policy compliance, as well as inform strategies to prevent policy evasion. Examining evolving industry tactics to promote flavoured products in response to regulatory changes can help authorities and practitioners assess policy effectiveness and inform future design and implementation approaches.

A content analysis of heated tobacco product business in Hong Kong on Facebook

Heated tobacco products (HTPs) are increasingly popular in Hong Kong (HK) even though they have not been formally launched and the sale of duty-not-paid tobacco sticks is illegal. We investigated how Facebook was used against regulations to sell HTPs in HK. We screened Facebook pages run by HTP businesses targeting HK users in June 2019 and included pages with over 300 "Likes" for inductive content analysis by coding their "About" descriptions and all posts including comments published since January 2017. HTPs included heating devices, accessories, and tobacco sticks. Various attributes were recorded including methods of customer inquiries (telephone, Instant Messaging [IM], address), business responses (comments or private messages, PM), and services provided (warranty/repair). Among 30 pages (50.9% of all 59 eligible pages with related information on HTPs), two-thirds provided phone numbers (66.7%), IM accounts (65.5%), and addresses (66.7%). Most pages sold heating devices (26, 86.7%) and accessories (22, 73.3%) with over 72% providing phone numbers, IM accounts, or addresses. Only 8 pages (26.7%) sold tobacco sticks with 75.0% providing telephone numbers but fewer provided IM accounts (62.5%) and addresses (50.0%). All pages responded using PMs and only 12.5% also used comments. Warranty/repair services were provided by 43.3% of the pages. We found Facebook pages were used as dedicated stores to promote and sell HTPs including heating devices, accessories, and even illicit tobacco sticks in HK, a non-official market.

Tech, Sex, and E-cigarettes: The Gendering of Vape Promotion on Instagram

The promotion of vape products on social media has been implicated in increasing rates of e-cigarette usage, particularly among youth and young adults. While research has examined overall trends in vape-related content across a number of platforms, the role that social media "influencers" play in promoting vaping and potentially augmenting this public health crisis has been insufficiently explored. The present study examined 44,052 Instagram posts by 60 male presenting and 60 female presenting vape influencers to understand how influencer gender mediates the performance of vape culture online. Our textual and visual analysis of these influencers' posts over one year revealed significant bifurcations based on gender. Independent sample t-tests showed statistically significant gender differences in word frequency. Male-presenting influencers tended to emphasize their expertise with vape devices as technologies, while female-presenting influencers tended to focus on their own appearance. Further, factor analysis indicated six major categories of textual features, and multiple linear regression tests showed varying levels of user engagement with the different categories across both genders. Chi-square tests indicated that female-presenting influencers highlighted their own bodies in the visual content of their posts, whereas male presenting influencers often posted images of vape devices or their component parts alone. These findings suggest that gender presentation plays an important role in shaping vape influencers' promotional tactics and vape-related content on Instagram, and also provides insights into what kinds of content receive the most user engagement. This study can therefore help inform interventions to mitigate the impact of social media vape promotion.

Association Between Exposure to Tobacco Content on Social Media and Tobacco Use: A Systematic Review and Meta-analysis

Importance

Exposure to tobacco-related content on social media may foster positive attitudes toward tobacco products and brands, and influence the likelihood of initiating or continuing use of tobacco, especially among adolescents and young adults.

Objective

To perform the first systematic review and meta-analysis, to our knowledge, on studies that examined the association between exposure to tobacco content on social media and lifetime tobacco use, past 30-day tobacco use, and susceptibility to use tobacco among never users.

Data Sources

Tobacco, social media, and marketing search terms were entered into online databases, including MEDLINE, ISI Web of Science, Scopus, and PsychINFO. Study characteristics, including research design and methods, sampling strategy, and demographics, were assessed for each study.

Study Selection

Studies reporting odds ratios (ORs) for self-reported exposure to, or experimentally manipulated, tobacco content on social media and lifetime tobacco use, past 30-day tobacco, and susceptibility to use tobacco among never users. The systematic search produced 897 independent articles, of which 29 studies met inclusion criteria.

Data Extraction and Synthesis

A 3-level random-effects meta-analysis was used to estimate ORs, 95% CIs, and heterogeneity (I2) for each tobacco use outcome. Study quality and publication bias were assessed.

Main Outcomes and Measures

Lifetime tobacco use, past 30-day tobacco use, and susceptibility to use tobacco among never users. Tobacco use included e-cigarettes, cigarettes, and other (cigar, hookah, smokeless tobacco).

Results

The total sample size across the 24 included datasets was 139 624, including 100 666 adolescents (72%), 20 710 young adults (15%), and 18 248 adults (13%). Participants who were exposed to tobacco content on social media, compared with those who were not exposed, had greater odds of reporting lifetime tobacco use (OR, 2.18; 95% CI, 1.54-3.08; I2 = 94%), past 30-day tobacco use (OR, 2.19; 95% CI, 1.79-2.67; I2 = 84%), and susceptibility to use tobacco among never users (OR, 2.08; 95% CI, 1.65-2.63; I2 = 73%). Subgroup analyses showed similar associations for tobacco promotions, active engagement, passive engagement, lifetime exposure to tobacco content, exposure to tobacco content on more than 2 platforms, and exposure to tobacco content among adolescents and young adults.

Conclusions and Relevance

Findings suggest that a comprehensive strategy to reduce the amount of tobacco content on social media should be developed by federal regulators. Such actions may have downstream effects on adolescent and young adult exposure to protobacco content, and ultimately tobacco use behaviors.

The Reshaping of the E-Cigarette Retail Environment: Its Evolution and Public Health Concerns

E-cigarette use represents a public health controversy in the US and globally. Despite the potential of e-cigarettes to support cigarette cessation, their use increases health risks and risk for addiction, particularly in young people. Various federal, state, and local laws have impacted tobacco retail in general and e-cigarettes in particular. In the US, 2019–2020 federal laws increased in the minimum legal sales age for tobacco to 21 and banned flavored cartridge-based e-cigarettes. Many states and localities were early adopters of Tobacco 21 and implemented more comprehensive flavor restrictions than the federal ban. Meanwhile, cannabis retail is increasingly being legalized in the US—while cannabis-based product regulation has notable gaps at the federal, state, and local levels. These regulatory complexities have impacted specialized retailers selling e-cigarettes, including “vape shops” that exclusively sell e-cigarettes, “smoke shops” that sell e-cigarettes and other tobacco (and potentially CBD/THC and other un- or under-regulated products), and online retail. This commentary outlines public health concerns related to: (1) youth access; (2) consumer exposure to a broader range of tobacco products and marketing in retail settings where they may seek products to aid in cigarette cessation (i.e., such broad product exposure could hinder cessation attempts); (3) consumer exposure to un-/under-regulated products (e.g., delta-8-THC, kratom); and (4) federal, state, and local regulations being undermined by consumer access to prohibited products online and via the mail. These concerns underscore the need for ongoing surveillance of how retailers and consumers respond to regulations.

The impact of e-cigarette product place in music videos on susceptibility to use e-cigarettes among young adults: An experimental investigation

INTRODUCTION

Product placement in music videos is a growing promotional strategy. This study examined the impact of e-cigarette product placement and imagery in music videos on susceptibility to use e-cigarettes among young adults.

METHODS

A non-probability sample of young adults (18 to 24) in Southern California were recruited to participate in an experiment over Zoom. Participants were randomized into a treatment or a control group. The treatment group watched seven music videos with e-cigarette product placement and imagery. The control group watched the same seven music videos with all e-cigarette product placement and imagery digitally removed. Participants completed a questionnaire after watching the music videos. The focus of the analysis was on susceptibility to use e-cigarettes in the future among never users (n = 303).

RESULTS

Participants in the treatment group who had never used e-cigarettes were more likely to report intentions to try e-cigarettes in the future (OR = 1.94, 95% CI [1.08, 3.54], compared to participants in the control group. Participants in the treatment group who had never used e-cigarettes were more likely to report peer influence (OR = 1.97, 95% CI [1.19, 3.32], compared to participants in the control group. While these subitems of susceptibility to use e-cigarettes were statistically significant, the relationship between the treatment group and the composite measure of susceptibility was not.

CONCLUSION

Exposure to e-cigarette product placement in music videos may increase young adults' intentions to try e-cigarettes in the future. Federal, state, and local tobacco control regulatory bodies should consider strategies to reduce e-cigarette product placement in music videos.

Exploring Factors That Predict Marketing of e-Cigarette Products on Twitter: Infodemiology Approach Using Time Series

Background

Electronic nicotine delivery systems (known as electronic cigarettes or e-cigarettes) increase risk for adverse health outcomes among naïve tobacco users, particularly youth and young adults. This vulnerable population is also at risk for exposed brand marketing and advertisement of e-cigarettes on social media. Understanding predictors of how e-cigarette manufacturers conduct social media advertising and marketing could benefit public health approaches to addressing e-cigarette use.

Objective

This study documents factors that predict changes in daily frequency of commercial tweets about e-cigarettes using time series modeling techniques.

Methods

We analyzed data on the daily frequency of commercial tweets about e-cigarettes collected between January 1, 2017, and December 31, 2020. We fit the data to an autoregressive integrated moving average (ARIMA) model and unobserved components model (UCM). Four measures assessed model prediction accuracy. Predictors in the UCM include days with events related to the US Food and Drug Administration (FDA), non-FDA-related events with significant importance such as academic or news announcements, weekday versus weekend, and the period when JUUL maintained an active Twitter account (ie, actively tweeting from their corporate Twitter account) versus when JUUL stopped tweeting.

Results

When the 2 statistical models were fit to the data, the results indicate that the UCM was the best modeling technique for our data. All 4 predictors included in the UCM were significant predictors of the daily frequency of commercial tweets about e-cigarettes. On average, brand advertisement and marketing of e-cigarettes on Twitter was higher by more than 150 advertisements on days with FDA-related events compared to days without FDA events. Similarly, more than 40 commercial tweets about e-cigarettes were, on average, recorded on days with important non-FDA events compared to days without such events. We also found that there were more commercial tweets about e-cigarettes on weekdays than on weekends and more commercial tweets when JUUL maintained an active Twitter account.

Conclusions

e-Cigarette companies promote their products on Twitter. Commercial tweets were significantly more likely to be posted on days with important FDA announcements, which may alter the narrative about information shared by the FDA. There remains a need for regulation of digital marketing of e-cigarette products in the United States.

Health Communication through Chinese Media on E-Cigarette: A Topic Modeling Approach

Background: Electronic cigarettes (e-cigarettes) have been a newsworthy topic in China. E-cigarettes are receiving greater consumer attention due to the rise of the Chinese e-cigarettes industry. In the past decade, e-cigarettes have been widely debated across the media, particularly their identity and their health effects. Objective: this study aims to (1) find the key topics in e-cigarette news and (2) provide suggestions for future media strategies to improve health communication. Method: We collected Chinese e-cigarettes news from 1 November 2015 to 31 October 2020, in the Huike (WiseSearch) database, using “e-cigarettes” (Chinese: “电子烟”) as the keyword. We used the Jieba package in python to perform the data cleaning process and the Dirichlet allocation (LDA) topic modeling method to generate major themes of the health communication through news content. Main finding: through an analysis of 1584 news articles on e-cigarettes, this paper finds 26 topics covered with 4 themes as regulations and control (n = 475, 30%), minor protection (n = 436, 27.5%), industry activities (n = 404, 25.5%), and health effects (n = 269, 17%). The peak and decline of the number of news articles are affected by time and related regulations. Conclusion: the main themes of Chinese news content on e-cigarettes are regulations and control, and minor protection. Newspapers should shoulder the responsibilities and play an important role in health communication with balanced coverage.

Exposure to tobacco and betel nut content on social media, risk perceptions, and susceptibility to peer influence among early adolescents in Guam

Introduction

This study aimed to examine the associations between exposure to tobacco and betel nut-related content on social media, perceived risks of tobacco and betel nut use, and susceptibility to peer influence for tobacco and betel nut use among adolescents living in Guam, a United States-Affiliated Pacific Island in the Western Pacific.

Methods

A representative survey of adolescents (N = 670) attending public middle schools on Guam was conducted. The survey measured exposure to tobacco and betel nut content on the following social media platforms: (a) Facebook, (b) Twitter, (c) Instagram, (d) Snapchat, and (e) WhatsApp. The survey also measured perceived risks of tobacco and betel nut use and susceptibility to peer influence for tobacco and betel nut use.

Results

Guam adolescents' exposure to tobacco-related content on social media was found to be associated with lower perceived risks toward the use of tobacco (β = -0.18, p < 0.001) and betel nut (β = -0.16, p < 0.001). Also, exposure to tobacco-related content on social media was found to be associated with higher levels of susceptibility to peer influence for uses of both tobacco (β = 0.10, p < 0.05) and betel nut (β = 0.15, p < 0.001). Similarly, exposure to betel nut-related content on social media was associated with lower perceived risks of using betel nut (β = -0.20, p < 0.001) and tobacco (β = -0.24, p < 0.001). Also, exposure to betel nut-related content on social media was associated with increased susceptibility to peer influence for use of both betel nut (β = 0.35, p < 0.001) and tobacco (β = 0.29, p < 0.001).

Conclusions

Adolescents' exposure to tobacco- and betel nut-related content on social media may influence attitudinal risk factors associated with tobacco and betel nut use.

Online Tobacco Advertising and Current Chew, Dip, Snuff and Snus Use among Youth and Young Adults, 2018-2019

OBJECTIVE

To understand the relationship between exposure to online tobacco advertising and current smokeless tobacco use in the context of tobacco control policies.

METHODS

Three waves of a national probability-based sample of (n = 15,985) youth and young adults were used. Analysis consisted of GEE logistic models controlling for social media use, demographics, tobacco use, average price of smokeless tobacco inclusive of taxes, smoke-free indoor air laws (SFIA) and state tobacco control expenditures.

RESULTS

Frequent exposure to tobacco advertising on social media is associated with greater odds of current smokeless use (aOR: 2.05, 95% CI: 1.62, 2.60). Higher prices and SFIA coverage were associated with reduced current smokeless use when examined separately from other tobacco policy variables (aOR: 0.79, CI: 0.73, 0.85; aOR: 0.44, CI: 0.28, 0.70).

CONCLUSIONS

Greater exposure to tobacco advertising online is associated with greater odds of smokeless use among surveyed youth and young adults. This effect of social media marketing exposure on smokeless use outweighs the mitigating impact of existing tobacco control policies. The findings underscore the need for strong advertising regulation of evolving tobacco products, including smokeless products, on social media and surveillance of digital marketing tactics to young people.

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.

The Longitudinal Impact of Seeing and Posting Tobacco-related Social Media on Tobacco Use Behaviors Among Youth (Aged 12-17): Findings From the 2014-2016 Population Assessment of Tobacco and Health (PATH) Study

Introduction

This study examined the impact of seeing and posting tobacco-related content on social media on tobacco use outcomes in youth.

Methods

Longitudinal secondary analyses of youth in the nationally representative 2014-2015 Population Assessment of Tobacco and Health (PATH) study were conducted to examine the association between the interaction of (i) seeing and (ii) posting tobacco-related social media content with previous ever use of each tobacco product, and 3 outcomes in 2015-2016: past 30-day e-cigarette use, past 30-day combustible product use, and past 30-day dual use of e-cigarettes and at least one combustible product. Six weighted multiple logistic regression models (2 interaction exposures*3 outcomes) were used to assess these associations, while adjusting for covariates.

Results

Among youth never users in 2014-2015, seeing tobacco-related social media content was significantly associated with past 30-day e-cigarette use (AOR 1.92; 95% CI= 1.36-2.71), and past 30-day dual use of e-cigarettes and at least one combustible product (AOR= 2.11; 95% CI= 1.08- 4.13) in 2015-2016. Among youth ever users in 2014-2015, posting tobacco-related content on social media was significantly associated with all 3 outcomes: past 30-day day e-cigarette use (AOR= 2.09;95%CI=1.23-3.55), past 30-day combustible product use (AOR=2.86; 95%CI=1.67-4.88), and past 30-day dual use of these products (AOR=3.02;95%CI=1.45-6.31), after adjusting for covariates.

Conclusions

Seeing and posting tobacco-related content on social media predicts tobacco use among youth, nationwide. Results suggest that interventions and policies prohibiting tobacco-related content on social media are needed to curb the impact of social media on youth tobacco-use.

Tobacco Product Use and Associated Factors Among Middle and High School Students - National Youth Tobacco Survey, United States, 2021

PROBLEM/CONDITION

Commercial tobacco use is the leading cause of preventable disease, disability, and death in the United States. Most tobacco product use begins during adolescence. In recent years, tobacco products have evolved to include various combusted, smokeless, and electronic products.

PERIOD COVERED

2021.

DESCRIPTION OF SYSTEM

The National Youth Tobacco Survey (NYTS) is an annual, cross-sectional, school-based, self-administered survey of U.S. middle school (grades 6-8) and high school (grades 9-12) students. A three-stage cluster sampling procedure is used to generate a nationally representative sample of U.S. students attending public and private schools. NYTS is the only nationally representative survey of U.S. middle and high school students that focuses exclusively on tobacco use patterns and associated factors. NYTS provides data to support the design, implementation, and evaluation of comprehensive youth tobacco use prevention and control programs and to guide tobacco regulatory activities. Since 2019, NYTS has been administered electronically via tablet computers. Because of emergency COVID-19 protocols that were in place across the United States during the 2021 NYTS fielding window (January 18-May 21, 2021), the 2021 survey was administered using a web URL to allow participation by eligible students learning under varying instructional models (in-person, distance/virtual, and hybrid). In total, 50.8% of student respondents reported completing the survey in a school building or classroom and 49.2% at home or some other place. CDC and the Food and Drug Administration (FDA) analyzed data from the 2021 NYTS to assess tobacco product use patterns and associated factors among U.S. middle and high school students. Overall, 20,413 students (out of 25,149 sampled students; student response rate: 81.2%) completed the questionnaire from 279 schools (out of 508 sampled schools; school response rate: 54.9%). The overall response rate, defined as the product of the student and school response rates, was 44.6%. The sample was weighted to represent approximately 11.97 million middle school students and 15.44 million high school students. Students with missing information about grade level were excluded from the school-level analyses (n = 135).

RESULTS

In 2021, an estimated 34.0% of high school students (5.22 million) and 11.3% of middle school students (1.34 million) reported ever using a tobacco product (i.e., electronic cigarettes [e-cigarettes], cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, heated tobacco products, nicotine pouches, and bidis [small brown cigarettes wrapped in a leaf]). Current (past 30-day) use of a tobacco product was 13.4% for high school students (2.06 million) and 4.0% for middle school students (470,000). E-cigarettes were the most commonly currently used tobacco product, cited by 11.3% of high school students (1.72 million) and 2.8% of middle school students (320,000), followed by cigarettes, cigars, smokeless tobacco, hookahs, nicotine pouches, heated tobacco products, and pipe tobacco. Current use of any tobacco product was reported by 14.2% of students identifying as lesbian, gay, or bisexual (LGB) (versus 7.9% of heterosexual); 18.9% of students identifying as transgender (versus 8.2% of not transgender); and 14.2% of students reporting severe psychological distress (versus 5.5% with no distress). Among students who currently used each respective tobacco product, frequent use (on ≥20 days of the past 30 days) ranged from 17.2% for nicotine pouches to 39.4% for e-cigarettes. Among current users of any tobacco product, 79.1% reported using a flavored tobacco product; by product, e-cigarettes were the most commonly used flavored tobacco product. Among current users of any tobacco product, the most commonly reported source of access was from a friend (32.8%). Among students who currently used e-cigarettes, 53.7% used a disposable device, 28.7% used a prefilled/refillable pod or cartridge device, 9.0% used a tank or mod system (a system that can be customized by the user), and 8.6% did not know the device type. Among students who had ever used e-cigarettes, the most common reason for first trying them was "a friend used them" (57.8%); among current e-cigarette users, the most commonly cited reason for current use was "I am feeling anxious, stressed, or depressed" (43.4%). Among all middle and high school students, 75.2% reported past-year recognition of any antitobacco public education campaign ads. Exposure to marketing or advertising for any tobacco product was reported by 75.7% of students who had contact with an assessed potential source of tobacco product advertisements or promotions (going to a convenience store, supermarket, or gas station; using the Internet; watching television or streaming services or going to the movies; or reading newspapers or magazines). Among students who reported using social media, 73.5% had ever seen e-cigarette-related content. Among all students, perceiving "no" or "little" harm from intermittent tobacco product use was highest for e-cigarettes (16.6%) and lowest for cigarettes (9.6%). Among students who currently used any tobacco product, 27.2% had experienced cravings during the past 30 days; 19.5% reported wanting to use a tobacco product within 30 minutes of waking. Moreover, 65.3% of students who currently used tobacco products were seriously thinking about quitting the use of all products, and 60.2% had stopped using all products for ≥1 day because they were trying to quit during the past 12 months.

INTERPRETATION

In 2021, approximately one in 10 U.S. middle and high school students (9.3%) had used a tobacco product during the preceding 30 days. By school level, this represented more than one in eight high school students (13.4%) and approximately one in 25 middle school students (4.0%). E-cigarettes were the most commonly used tobacco product in 2021. Tobacco product use was higher among certain subpopulations, such as those identifying as LGB or transgender, or those reporting psychological distress. Importantly, approximately two thirds of students who currently used tobacco products were seriously thinking about quitting. However, factors that might continue to promote tobacco product use among U.S. youths, such as the availability of flavors, access to tobacco products, exposure to tobacco product marketing, and misperceptions about harm from tobacco product use, remained prevalent in 2021.

PUBLIC HEALTH ACTION

The continued monitoring of all forms of youth tobacco product use and associated factors through surveillance efforts including NYTS is important to the development of public health policy and action at national, state, and local levels. The 2021 NYTS was successfully administered during the COVID-19 pandemic using a web URL to allow participation by eligible students learning under varying instructional models. As a result of these modifications to the fielding procedures, any comparison of results between 2021 NYTS findings with previous years, including the direct attribution of any potential changes in tobacco product use, is not possible. Parents, educators, youth advocates, and health care providers can help protect youths from the harms of tobacco products, including e-cigarettes. In addition, the comprehensive and sustained implementation of evidence-based tobacco control strategies, combined with FDA's regulation of tobacco products, is important for reducing all forms of tobacco product use among U.S. youths.

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

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

#NicotineAddictionCheck: Puff Bar Culture, Addiction Apathy, and Promotion of E-Cigarettes on TikTok

This study aimed to classify and delineate types of user-generated content about the disposable e-cigarette Puff Bar shared on the popular video-based social media platform TikTok. We qualitatively analyzed 148 popular TikTok videos collected in July 2020. During an iterative process of data reduction and thematic analysis, we categorized videos by overarching genres and identified emergent themes. Young adults were engaged at all stages of the research process. Together, videos were viewed over 137 million times on TikTok. Seven genres of Puff Bar content emerged: skits and stories, shared vaper experiences, videos to show off, product reviews, product unboxing, promotion of Puff Bar, and crafts. Videos depicted Puff Bar users’ apathy about addiction and a lack of concern of the health effects of e-cigarette use. Additionally, Puff Bar promotion content from underground retailers was extensive and some targeted underage persons. Qualitative analysis of social media content can richly describe emerging online culture and illuminate the motivations of adolescent and young adult e-cigarette use. Social media can facilitate new product adoption; comprehensive e-cigarette regulation and enforcement can counteract these effects by closing loopholes through which new products emerge.

U.S. public opinion toward policy restrictions to limit tobacco product placement and advertising at point-of-sale and on social media

The Family Smoking Prevention and Tobacco Control Act granted the U.S. Food and Drug Administration authority to regulate tobacco advertising and promotion, including at the retail level, and preserved state, tribal, and local tobacco advertising and promotion authorities. Public health experts have proposed prohibiting point-of-sale tobacco advertisements and product displays, among other tobacco advertising restrictions. We examined the prevalence and correlates of public support, opposition, and neutrality toward proposed tobacco product placement and advertising restrictions at point-of-sale and on social media utilizing the National Cancer Institute's 2020 Health Information National Trends Survey (HINTS) (N = 3865), a cross-sectional, probability-based postal survey of U.S. addresses conducted from Feb 24, 2020 to June 15, 2020 (Bethesda, MD). Frequencies and unadjusted, weighted proportions were calculated for support, neutrality, and opposition toward the three policies under study, and weighted, adjusted multivariable logistic regression was employed to examine predictors of neutrality and opposition. Tests of significance were conducted at the p < 0.05 level. Sixty-two percent of U.S. adults supported a policy prohibiting tobacco product advertising on social media; 55% supported a policy restricting the location of tobacco product advertising at point-of-sale; and nearly 50% supported a policy to keep tobacco products out of view at the checkout counter. Neutrality and opposition varied by sociodemographic characteristics including age, sex, education, rurality, and presence of children in the household. Understanding public opinion toward tobacco product placement and advertising restrictions may inform policy planning and implementation.

Smokers' Likelihood to Engage With Information and Misinformation on Twitter About the Relative Harms of e-Cigarette Use: Results From a Randomized Controlled Trial

Background

Information and misinformation on the internet about e-cigarette harms may increase smokers’ misperceptions of e-cigarettes. There is limited research on smokers’ engagement with information and misinformation about e-cigarettes on social media.

Objective

This study assessed smokers’ likelihood to engage with—defined as replying, retweeting, liking, and sharing—tweets that contain information and misinformation and uncertainty about the harms of e-cigarettes.

Methods

We conducted a web-based randomized controlled trial among 2400 UK and US adult smokers who did not vape in the past 30 days. Participants were randomly assigned to view four tweets in one of four conditions: (1) e-cigarettes are as harmful or more harmful than smoking, (2) e-cigarettes are completely harmless, (3) uncertainty about e-cigarette harms, or (4) control (physical activity). The outcome measure was participants’ likelihood of engaging with tweets, which comprised the sum of whether they would reply, retweet, like, and share each tweet. We fitted Poisson regression models to predict the likelihood of engagement with tweets among 974 Twitter users and 1287 non-Twitter social media users, adjusting for covariates and stratified by UK and US participants.

Results

Among Twitter users, participants were more likely to engage with tweets in condition 1 (e-cigarettes are as harmful or more harmful than smoking) than in condition 2 (e-cigarettes are completely harmless). Among other social media users, participants were more likely to likely to engage with tweets in condition 1 than in conditions 2 and 3 (e-cigarettes are completely harmless and uncertainty about e-cigarette harms).

Conclusions

Tweets stating information and misinformation that e-cigarettes were as harmful or more harmful than smoking regular cigarettes may receive higher engagement than tweets indicating e-cigarettes were completely harmless.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 16082420; https://doi.org/10.1186/ISRCTN16082420

Relationships of Smoking Media Literacy with Smoking Behavior, Attitudes, and Susceptibility among Adolescents in the Republic of Korea

The literature has indicated that higher smoking media literacy (i.e., SML) can buffer adverse effects of exposure to pro-smoking media content (i.e., PMC) on smoking-related outcomes in adolescence. Thus, we aimed to investigate (a) SML levels among Korean adolescents and (b) relationships of SML with smoking behavior, attitudes, and susceptibility. In 2017, we collected cross-sectional data from nine middle or high schools in Korea, using a convenience sampling method (N = 476). For the first aim, we calculated the average score of SML. For the second aim, we conducted multinomial logistic regression (MLR), multiple linear regression, and binary multiple logistic regression. Additionally, we conducted Firth logistic regression and confirmed the robustness of our findings obtained from the MLR. The average SML score was 6.48 out of 10 points, indicating that our respondents' average SML was slightly above the middle level. In addition, after adjusting for factors potentially affecting associations between SML and the three smoking-related outcomes, we found significant protective relationships of SML with all smoking-related outcomes: smoking behavior, attitudes, and susceptibility. Given our findings, the enhancement of SML through education should be considered an important strategy to weaken the link between exposure to PMC and smoking-related outcomes.

National Trends of Adolescent Exposure to Tobacco Advertisements: 2012-2020

BACKGROUND AND OBJECTIVES

The objective of the current study is to evaluate the temporal trends in the prevalence of cigarette and electronic cigarette (e-cigarette) advertisement exposure by venue and sociodemographic correlates among US adolescents from 2012 to 2020.

METHODS

We conducted a serial cross-sectional analysis of nationally representative samples of middle and high school youth from the 2012-2020 National Youth Tobacco Survey. Advertisement exposure was defined as self-report of seeing advertisements "sometimes," "most of the time," and "always." The prevalence of cigarette (and other tobacco products) and e-cigarette advertisement exposure, including overall and at specific venues (Internet, press, screen, and retail stores), was estimated by survey year.

RESULTS

A total of 139 795 adolescents aged 11 to 19 years old were included in the analysis. The prevalence of exposure to combustible cigarette marketing remained high across all years (any venue ranging from 77.0% [2018] to 91.1% [2014]). An increasing trend for cigarette advertisement exposure was observed from 2017 to 2020 after a drop in 2015 (β2012-2015 = 2.8, P for trend < .001; β2017-2020 = .7, P for trend = .03), driven by retail store-based and Internet-based exposure. A similar increasing pattern in the estimated prevalence of e-cigarette marketing was observed (β2014-2016 = 4.6, P for trend < .001; β2017-2020 = 5.1, P for trend < .001).

CONCLUSIONS

Given the high estimated prevalence of cigarette and e-cigarette marketing exposure among US adolescents, further regulation efforts for both off-line and online tobacco marketing are needed to mitigate adolescent exposure to content regarding these products, reducing susceptibility to uptake.

Social media and E-cigarette use among US youth: Longitudinal evidence on the role of online advertisement exposure and risk perception

OBJECTIVES

Previous studies revealed a link between social media use and e-cigarette use among U.S. youth, but less is known about the mechanisms through which they interconnect. This study examined how social media and e-cigarette use are connected through online advertisement exposure and risk perception of e-cigarettes among U.S. youth.

METHODS

Youth aged 12-17 from the Public Assessment of Tobacco and Health (PATH) Study Waves 2-4 (2014-2018) were included (N = 6,208). This study integrated the incidental exposure framework and the risk perception framework to guide study conceptualization and variable selection. Generalized structural equation modeling was performed to investigate the sequential mediation relationship between social media and e-cigarette use through online e-cigarette advertisement exposure and risk perception of e-cigarette use.

RESULTS

Youth respondents with more social media use were more likely to be exposed to e-cigarette advertisement at Wave 2 (OR = 1.13, p < 0.001), which led to lower e-cigarette risk perception at Wave 3 (β = -0.07, p < 0.001). Higher e-cigarette risk perception at Wave 3 resulted in lower likelihood of e-cigarette use at Wave 4 (OR = 0.57, p < 0.001). High social media use at Wave 2 was directly associated with high likelihood of e-cigarette use at Wave 4 (OR = 1.11, p < 0.001).

CONCLUSIONS

The results indicate that social media use is associated with increased e-cigarette use through online e-cigarette advertisement exposure and subsequently decreased e-cigarette risk perception among U.S. youth. Our findings underscore the importance of regulating online e-cigarette advertisement, with the emphasis of avoiding information that could twist youth's risk perception of e-cigarettes, which may in turn curtail youth e-cigarette use.

Commercial determinants of youth smoking in ASEAN countries: A narrative review of research investigating the influence of tobacco advertising, promotion, and sponsorship

INTRODUCTION

Tobacco smoking is one of the leading causes of death and disability in the Association of Southeast Asian Nations (ASEAN). Despite implementation of some tobacco control measures, youth continue to initiate smoking. This narrative review outlines how tobacco advertising, promotion, and sponsorship (TAPS) may influence smoking attitudes and uptake among youth in the region.

METHODS

Nine electronic databases were searched on EBSCOhost to identify studies published up until December 2019. All studies published in English that investigated youth smoking and TAPS in ASEAN countries were included. Thematic analysis was used to investigate the influence of TAPS on youth smoking.

RESULTS

Thirty-seven studies were identified. This research showed that youth were exposed and receptive to tobacco advertising, which may contribute to positive attitudes towards tobacco brands and smoking. Studies also demonstrated that youth were exposed to point-of-sale (POS) advertisements or promotions and individual sales promotions. However, little research has explored how these strategies influence attitudes and consumption behaviors among youth, or, how online advertising and cigarette packet branding may influence youth smoking.

CONCLUSIONS

Youth in ASEAN countries continue to be exposed to TAPS, particularly through POS advertisements or promotions and individual sales promotions. There is also cause for concern about ‘below-the-line’ advertising and the increasing role of cigarette packaging as a promotional tool. These findings support calls for all ASEAN countries to ratify the Framework Convention on Tobacco Control (FCTC), introduce comprehensive bans on all forms of tobacco advertising, including POS advertising and cigarette pack displays, and implement plain packaging legislation for tobacco products.

Latent Profiles and Influencing Factors of Posttraumatic Stress Symptoms Among Adults During the COVID-19 Pandemic

The COVID-19 pandemic severely affected public health and the prevalence of posttraumatic stress symptoms among adults in Hubei Province, China. In this study, a total of 2,930 (662 males and 2,268 females) adults answered a questionnaire obtaining information on their demographics, posttraumatic stress symptoms (i.e., intrusion and avoidance), social media exposure, social media involvement, and self-efficacy. Results of the latent profile analysis identified four latent profiles of posttraumatic stress symptoms, which are, no symptoms, high intrusion–low avoidance, moderate symptoms, and high symptoms. The multinomial logistic regression analyses revealed the contributors to the posttraumatic stress symptoms subgroups. Adults with high social media involvement were classified into the high intrusion–low avoidance group, whereas adults with low self-efficacy were included in the moderate symptoms group. Meanwhile, adults with high social media involvement and low self-efficacy were included in the high symptoms group. Interventions may focus on decreasing social media involvement for the adults in the high Intrusion–low avoidance group, improving self-efficacy for the adults in the moderate symptoms group, and reducing social media involvement and improving self-efficacy for the adults in the high symptoms group.

Digital marketing of smokeless tobacco: A longitudinal analysis of exposure and initiation among young adults

OBJECTIVES

This study examines the relationships between recall of exposure to digital marketing of smokeless tobacco, via the internet and social media, and subsequent initiation of smokeless tobacco use at one-year follow-up, among young adult never users of smokeless tobacco in Texas.

METHODS

Data were from waves 6 (Spring 2017) and 7 (Spring 2018) of the Marketing and Promotions Across Colleges in Texas Study (Project M-PACT); a longitudinal study of two- and four-year Texas college students. Participants were 2731 young adult never smokeless tobacco users (ages 20-32) with complete data at both assessment periods. A multi-level, multiple logistic regression model was applied, accounting for school clustering, to examine the relationship between recall of exposure to digital marketing of smokeless tobacco at baseline (wave 6) and smokeless tobacco use initiation at one-year follow-up (wave 7). Analyses controlled for important baseline covariates (socio-demographic factors, other marketing exposure, other tobacco product use).

RESULTS

Overall, 14.6% of never smokeless tobacco users reported exposure to smokeless tobacco marketing via digital media. Exposure to digital marketing of smokeless tobacco at baseline was associated with greater odds of smokeless tobacco use initiation among young adult never users (AOR: 2.14; 95%CI: 1.12 - 4.06) at one-year follow-up.

CONCLUSIONS

Findings reveal exposure to smokeless tobacco marketing via digital media was common. Further, there appears to be a strong relationship between this exposure and subsequent smokeless tobacco use among young adult never smokeless tobacco users.

Effects of Social Media on Adolescents' Willingness and Intention to Use E-Cigarettes: An Experimental Investigation

INTRODUCTION

This study examined the effects of experimentally manipulated social media exposure on adolescents' willingness and intention to use e-cigarettes.

AIMS AND METHODS

Participants were 135 adolescents of age 13-18 (52.6% female, mean age = 15.3) in California. Participants viewed six social media posts online in a 2 (post source: peer or advertisement) × 2 (e-cigarette content exposure: heavy or light) between-subjects design. Analyses were weighted to population benchmarks. We examined adolescents' beliefs, willingness, and intention to use e-cigarettes in association with social media use intensity in daily life and with experimentally manipulated exposure to social media posts that varied by source (peer or advertisement) and content (e-cigarette heavy or light).

RESULTS

Greater social media use in daily life was associated with greater willingness and intention to use e-cigarettes and more positive attitudes, greater perceived norms, and lower perceived danger of e-cigarette use (all p-values <.01). In tests of the experimental exposures, heavy (vs. light) e-cigarette content resulted in greater intention (p = .049) to use e-cigarettes and more positive attitudes (p = .019). Viewing advertisements (vs. peer-generated posts) resulted in greater willingness and intention (p-values <.01) to use e-cigarettes, more positive attitudes (p = .003), and greater norm perceptions (p = .009). The interaction effect of post source by post content was not significant for any of the outcomes (all p-values >.529).

CONCLUSIONS

Greater social media use and heavier exposure to advertisements and e-cigarette content in social media posts are associated with a greater risk for e-cigarette use among adolescents. Regulatory action is needed to prohibit sponsored e-cigarette content on social media platforms used by youth.

IMPLICATIONS

Adolescents who use social media intensely may be at higher risk for e-cigarette use. Even brief exposure to e-cigarette content on social media was associated with greater intention to use and more positive attitudes toward e-cigarettes. Regulatory action should be taken to prohibit sponsored e-cigarette content on social media used by young people, including posts by influencers who appeal to young people.

Sex differences in associations between receiving and sharing tobacco-related information and tobacco product use among Appalachian Youth

INTRODUCTION

Given that Appalachian youth tobacco use rates are higher than the US national average, it is important to understand whether sex differences shape associations between receiving and sharing product information and using tobacco.

METHODS

Middle and high school students in rural Appalachia (n=1038) were surveyed about tobacco-related perceptions and behaviors, including ways youth receive and share conventional tobacco-related and e-cigarette-related information. Youth were characterized as tobacco users (i.e. ever or current users of cigarettes, smokeless tobacco, or e-cigarettes) or never users. Descriptive characteristics were compared by tobacco use and sex. Adjusted logistic regression models evaluated associations between communication channels and tobacco use. Models were stratified by sex to examine effect modification.

RESULTS

Approximately one-third of Appalachian youth (33.8%) were tobacco users and use varied by sex (males: 54.4%; females: 45.6%). Male (OR=1.75; 95% CI: 1.18-2.60) and female (OR=2.30; 95% CI: 1.53-3.47) youth who received e-cigarette-related information through friends and family (FF) had higher odds of tobacco use. Additionally, females who received e-cigarette-related information through public displays and digital media had nearly two-fold increased odds of tobacco use. Although sharing conventional tobacco-related and e-cigarette-related information through FF was associated with increased odds of tobacco use among both sexes, these relationships were stronger among females.

CONCLUSIONS

Although specific communication channels were associated with tobacco use, associations involving receiving and sharing e-cigarette information were more pronounced in female tobacco users. Consideration of sex differences in how youth receive and share tobacco-related information may benefit tobacco prevention interventions.

Exploring How Social Media Exposure and Interactions Are Associated With ENDS and Tobacco Use in Adolescents From the PATH Study

INTRODUCTION

Tobacco use is a current public health epidemic that puts individuals at risk for many health conditions and diseases, and adolescents are at high risk for the initiation and persistence of tobacco use behaviors partly due to engagement with social media content. The objective of this study is to examine the association between engaging in social media behaviors and patterns of electronic nicotine delivery systems (ENDS) and tobacco use at a 1-year follow-up among 11 279 adolescents from the PATH study.

METHODS

Five social media variables were questioned at Wave 2 and then compared to ENDS and tobacco status transitions (i.e., initiation, persistence, and escalation) at a 1-year follow-up, respectively. Survey-weighted multivariable logistic regression models were used to calculate adjusted odds ratios and 95% confidence interval.

RESULTS

Passive behaviors on social media were related to higher likelihoods of starting to use ENDS and other tobacco products. Additionally, active behaviors on social media were related to higher likelihoods for the initiation and persistence of tobacco use. In particular, sending tobacco content to other users was further associated with a higher likelihood of escalation of tobacco product use.

DISCUSSION

Both exposure to and interactions with social media tobacco content had a significant impact on the patterns of ENDS and tobacco use in adolescents. Due to the amount of time adolescents spend engaging with online content, social media may be a critical place in which to intervene, possibly with the use of antitobacco or tobacco prevention messages.

IMPLICATIONS

The results of this study have implications for public health and the policies surrounding adolescents and their exposure to social media. Reducing the ENDS and tobacco content to which adolescents are exposed has the potential to decrease the instances of initiation and persistence of ENDS and tobacco use. Intervening on social media may prevent or slow the progression of ENDS and tobacco use, and increase motivation and actions toward the cessation of tobacco use in adolescents.

Investigating the role of familial and peer-related factors on electronic nicotine delivery systems (ENDS) use among U.S. adolescents

INTRODUCTION

Tobacco use is a public health concern, and adolescents are at an increased risk of starting and continuing to use tobacco relative to other age groups. Parent involvement and other social environmental factors may influence the development and persistence of tobacco use behaviors in adolescence. This study used the nationally representative Population Assessment of Tobacco and Health (PATH) study data set, and responses from 7025 adolescent participants were analyzed to illustrate the longitudinal relationship between social environment influences and use of adolescent electronic nicotine delivery systems (i.e., ENDS).

METHODS

Social environmental factors were assessed at Wave 3 and then compared to electronic nicotine delivery systems (ENDS) status transitions (i.e., initiation, expansion, persistence) at follow-up. Survey-weighted multivariable logistic regression models were used to calculate adjusted odds ratios (AOR) and 95% confidence intervals (CI).

RESULTS

Initiation and persistence of ENDS use were associated with tobacco availability in the house, perception of having no adverse parent reaction to discovering ENDS use and having a best friend who uses ENDS. Initiation of ENDS use was further associated with having biological relatives who have ever been diagnosed with a substance use disorder (SUD) and persistence of ENDS use was also positively associated with lack of in-house rules. Parents talking about ENDS use with adolescents had no association across all three outcomes.

CONCLUSIONS

Findings suggest that parental and environmental factors alter the risk of initiation and persistence of ENDS and tobacco use in adolescents, and these should be considered when working with this at-risk population.

Changing Alcohol Cravings Using Social Media Comments

Background: Alcohol marketing has proliferated on social media. When exposed to social media advertisements, users view comments written in response to the ad and user engagement metrics, in addition to the ad itself. Here, the independent effect of different types of comments on alcohol craving was assessed. Methods: In all, n = 722 participants were randomized to view either no comments, pro-drinking comments, anti-drinking comments, warning labels, or industry responsibility messages associated with six alcohol ads. Alcohol cravings, measured using the Desires for Alcohol Questionnaire (DAQ), were assessed before and after ad exposure. Smoking urges were also assessed. The significance of main effects was determined using repeated-measures ANCOVA. Results: Warning labels significantly decreased scores on the desires and intentions to drink DAQ sub-scale (p = .025) and decreased smoking urges (p = .024). Pro-drinking comments significantly increased scores on the control of drinking sub-scale (p = .006). Conclusions: The findings suggest that user-generated comments can influence the desire to drink and smoking urges, beyond the effects of ads themselves. If so, alcohol warning labels may decrease alcohol cravings when used in this way. Additionally, to limit the loss of control over drinking, the ability of social media users to post pro-drinking comments may need to be curtailed.

Marketing Content on E-Cigarette Brand-Sponsored Facebook Profile Pages

INTRODUCTION

E-cigarettes are marketed on brand-sponsored Facebook profile pages despite Facebook's policy to prohibit e-cigarette marketing on their platform. We aimed to identify e-cigarette marketing strategies used and products marketed on brand-sponsored Facebook profiles and assess whether these strategies and featured products differ by user engagement.

METHODS

We examined up to 10 recent Facebook posts on 26 e-cigarette brand-sponsored profile pages uploaded between August 1 and November 31, 2016. We identified positive engagement (i.e. "like," "love"), negative engagement (i.e. "sad," "angry"), post type (e.g. link, photo), type of sales promotion (e.g. giveaways, discounts), non-sales promotion (e.g. event promotion without product marketing), and marketed products (e.g. e-cigarettes, e-liquids).

RESULTS

We examined 225 Facebook posts. Engagement was modest (e.g. Median "likes" = 8 [Min = 0, Max = 591]). The most common post types were photos (52.6%) and links (35.5%). Of all links, 83.7% were links to online shops. Of all posts, 35.0% had overt sales promotional content, 32.0% featured non-sales promotional content, and 68.0% featured an e-cigarette product. The most commonly featured product was an e-cigarette device (50.6%). Posts with more positive engagement included giveaways (versus sales [p = 0.009]) and posts marketing vaping devices (versus e-liquids [p = 0.004)]). Negative engagement was not associated with marketing strategies or products. Of the brand-sponsored profile pages, 42.3% could be accessed by underage users.

DISCUSSION

E-cigarettes are marketed on Facebook using a variety of promotional strategies. Importantly, underage youth often can access this marketing content. Comprehensive tobacco control policies that restrict e-cigarette marketing on social media are needed urgently.

Estimating E-Cigarette Use Prevalence among US Adolescents UsingVaping-Related Online Search Trends

Introduction: Adolescent e-cigarette use is a developing phenomenon. Greater surveillance of underage use is necessary to inform e-cigarette policy and mitigate adolescent e-cigarette use. Accurate prevalence estimates for adolescent e-cigarette use are provided by large national surveys. However, these surveys are costly and provide only annual estimates. To obtain more affordable estimates faster and more frequently, novel methods are required. Methods: Online search term popularity data were taken from Google Trends. Interest in vaping-related search terms were followed monthly from January 2011 to November 2020. Time-lagged zero-normalized cross-correlations were performed between the Google data and current (past 30 day) high-school e-cigarette use prevalence estimates from the National Youth Tobacco Survey (NYTS). The search interest data were then calibrated to the NYTS data to estimate adolescent e-cigarette use prevalence using online searches. Results: Maximum correlation coefficients of 0.979 for "vapes" and 0.938 for "vape" were obtained when search interest lagged use prevalence by one month, and 0.970 for "vape pen" when the lag was two months (p < 0.001 for all). Calibrating the search term data to NYTS provided a high-school current e-cigarette use prevalence estimate of 12.1-18.4% for November 2020, suggesting adolescent use of e-cigarettes has continued to decline since the NYTS estimate of 19.6% for January-March 2020. Conclusions: Online search trend data may provide reasonably reliable and more frequent estimates of adolescent e-cigarette use prevalence at substantially lower costs than traditional surveys. Such additional data may help to assess immediate impacts of policies and events.

Comparing Risk Factors for Past 30-day E-cigarette and Combustible Tobacco Use: A Longitudinal Analysis of the Texas Adolescent Tobacco and Marketing Surveillance Study (2014-2017)

SIGNIFICANCE

Youth use of e-cigarettes is reaching 'epidemic proportions,' even as combustible tobacco use is declining. Comparison of risk factors that are uniquely associated with e-cigarette and combustible tobacco use among adolescents is warranted.

METHODS

Six waves of data from the Texas Adolescent Tobacco and Marketing Surveillance (TATAMS) study (n=3907; N=461,069; 2014-2017) were used in this analysis. A random intercept logistic regression model was used to compare intrapersonal, interpersonal, and environmental risk factors for use of both products based on the Social Ecological Model.

RESULTS

Risk factors that were significantly associated with both past 30-day use of e-cigarette and combustible tobacco products over time included past 30-day use of marijuana and alcohol, social acceptability of product use, having friends and family members who used the products, and male gender. Increasing age, worse academic performance, higher sensation seeking score, higher recall of social media promotion in the past 30 days, and lower positive affect score were associated with past 30-day use of combustible tobacco only. White race was associated with past-30 day use of e-cigarettes only.

CONCLUSION

Involving peers and parents in preventive interventions designed to reduce uptake of these products is paramount, as is the need to address other substance use, like alcohol and marijuana. Efforts should also be made to create a social climate that makes tobacco use (e-cigarettes and combustible products) less acceptable and desirable.