An Examination of Electronic Cigarette Content on Social Media: Analysis of E-Cigarette Flavor Content on Reddit

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.

Investigating Substance Use via Reddit: Systematic Scoping Review

BACKGROUND

Reddit's (Reddit Inc) large user base, diverse communities, and anonymity make it a useful platform for substance use research. Despite a growing body of literature on substance use on Reddit, challenges and limitations must be carefully considered. However, no systematic scoping review has been conducted on the use of Reddit as a data source for substance use research.

OBJECTIVE

This review aims to investigate the use of Reddit for studying substance use by examining previous studies' objectives, reasons, limitations, and methods for using Reddit. In addition, we discuss the implications and contributions of previous studies and identify gaps in the literature that require further attention.

METHODS

A total of 7 databases were searched using keyword combinations including Reddit and substance-related keywords in April 2022. The initial search resulted in 456 articles, and 227 articles remained after removing duplicates. All included studies were peer reviewed, empirical, available in full text, and pertinent to Reddit and substance use, and they were all written in English. After screening, 60 articles met the eligibility criteria for the review, with 57 articles identified from the initial database search and 3 from the ancestry search. A codebook was developed, and qualitative content analysis was performed to extract relevant evidence related to the research questions.

RESULTS

The use of Reddit for studying substance use has grown steadily since 2015, with a sharp increase in 2021. The primary objective was to identify tendencies and patterns in various types of substance use discussions (52/60, 87%). Reddit was also used to explore unique user experiences, propose methodologies, investigate user interactions, and develop interventions. A total of 9 reasons for using Reddit to study substance use were identified, such as the platform's anonymity, its widespread popularity, and the explicit topics of subreddits. However, 7 limitations were noted, including the platform's low representativeness of the general population with substance use and the lack of demographic information. Most studies use application programming interfaces for data collection and quantitative approaches for analysis, with few using qualitative approaches. Machine learning algorithms are commonly used for natural language processing tasks. The theoretical, methodological, and practical implications and contributions of the included articles are summarized and discussed. The most prevalent practical implications are investigating prevailing topics in Reddit discussions, providing recommendations for clinical practices and policies, and comparing Reddit discussions on substance use across various sources.

CONCLUSIONS

This systematic scoping review provides an overview of Reddit's use as a data source for substance use research. Although the limitations of Reddit data must be considered, analyzing them can be useful for understanding patterns and user experiences related to substance use. Our review also highlights gaps in the literature and suggests avenues for future research.

Public Perceptions and Discussions of Premium Cigars on Reddit

Introduction

While premium cigars have similar addictive, toxic, and carcinogenic constituents as other cigars and cigarettes, about 1% of the US adults reported premium cigar use from 2010 to 2019. This study aimed to understand public perceptions and discussions of premium cigars on Reddit, one of the most popular social media platforms.

Methods

Using keywords such as "premium cigar", we extracted 2,238 Reddit posts from Reddit Archive between July 2019 and June 2021. Among them, 1,626 posts were related to premium cigars. By employing the inductive approach, we manually coded each Reddit post on premium cigars to understand public perceptions and discussions of premium cigars by summarizing them into different topics and subtopics.

Results

Longitudinal analysis showed that the number of Reddit posts on premium cigars increased since June 2020. Content analysis showed that among Reddit posts related to premium cigars, the most popular topic is "Information sharing" (75.72%), in which Reddit users shared their perceptions about premium cigars, asked for advice, and provided some recommendations about premium cigars. Over one-quarter of posts (27.17%) are sharing user experiences of premium cigars (such as taste). Nearly one-fifth (18.99%) of posts are discussing the affordability of premium cigars. In addition, 7.87% of posts are discussing legal/policy issues related to premium cigars, and 6.82% of posts are related to the health risks of premium cigars compared to cigarettes.

Conclusions

Public perceptions including misperceptions, user experiences, and affordability related to premium cigars have been actively discussed on Reddit.

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.

An Investigation of Age-Differentiated Conversations About Electronic Nicotine Delivery Systems on Reddit

Introduction

This study analyzes age-differentiated Reddit conversations about ENDS.

Methods

This study combines 2 methods to (1) predict Reddit users' age into 2 categories (13-20 years [underage] and 21-54 years [of legal age]) using a machine learning algorithm and (2) qualitatively code ENDS-related Reddit posts within the 2 groups. The 25 posts with the highest karma score (number of upvotes minus number of downvotes) for each keyword search (i.e., query) and each predicted age group were qualitatively coded.

Results

Of 9, the top 3 topics that emerged were flavor restriction policies, Tobacco 21 policies, and use. Opposition to flavor restriction policies was a prominent subcategory for both groups but was more common in the 21-54 group. The 13-20 group was more likely to discuss opposition to minimum age laws as well as access to flavored ENDS products. The 21-54 group commonly mentioned general vaping use behavior.

Conclusions

Users predicted to be in the underage group posted about different ENDS-related topics on Reddit than users predicted to be in the of-legal-age group.

Describing Memes Referencing Vaping: Thematic Analysis

Background: Memes, images or videos with text overlay that embody a concept or belief about the contemporary society, are endemic to Internet culture, are popular among youth and diffuse rapidly across social media platforms. E-cigarettes and vaping have grown in popularity in the era of Internet culture however there is little research describing the intersection of memes and vaping. This is an important gap in the literature as memes may be part of the broader online e-cigarette information landscape that can normalize vaping among young people. Memes could also point to emerging trends in product preferences. This study content analyzed memes to identify key themes, characters and vape products depicted therein. Methods: Data were drawn from a sub-reddit devoted to vaping-related memes. Memes were electronically copied from the forum to analyze (n = 527). Using an inductive approach, the research team identified 14 themes. Results: In-group communication (n = 202, 38.33%) was the most predominant theme followed by Critique of vaping regulations and public perceptions (n = 76, 14.42%), and Vape device modifications and hacks (n = 62, 11.76%). Memes included Cartoons (n = 124, 23.53%), Celebrities (n = 75, 14.23%), and Fictional characters (n = 53, 10.06%). Memes referenced Tanks or mods (n = 120, 22.77%), Component parts (n = 96, 18.22%) and E-liquids/Nicotine salts (n = 81, 15.37%). Conclusion: Memes referenced in-group communication and cartoons among other youth friendly images, raising concern about the potential to normalize vaping-related behaviors. Future research should monitor emerging vape devices and determine the impact of memes on attitudes and behaviors among adolescents and young adults. Implications: Given the popularity and reach of memes among youth, continuous monitoring of vaping-related memes may reveal aspects that may be addressed in vaping prevention campaigns.

The actual and anticipated effects of restrictions on flavoured electronic nicotine delivery systems: a scoping review

Objective

To synthesize the outcomes of policy evaluations of flavoured electronic nicotine delivery systems (ENDS) restrictions.

Data sources

PubMed, Scopus, Embase and Web of Science before May 3, 2022.

Study selection

Studies that report sales, behaviour, or compliance outcomes related to implemented or hypothetical ENDS flavour restrictions.

Data extraction

Restriction details, whether implemented or hypothetical, whether additional products were restricted, jurisdictional level, study locations, and outcomes classified by sales, behaviour, and compliance.

Data synthesis

We included 30 studies. Of those, 26 were conducted exclusively in the US, two in India, and two surveyed respondents in multiple countries, including the US. Twenty-one evaluated implemented restrictions, while nine considered hypothetical restrictions. Five studies evaluated product sales, 17 evaluated behaviour, and 10 evaluated compliance, with two studies reporting multiple outcomes. Two studies reported an increase and one a reduction in cigarette sales following restrictions, while three reported reductions in ENDS sales. Behavioural studies presented a mixed view of the impacts of regulations on ENDS and cigarette use. However, the use of disparate outcomes limits the comparability of studies. Studies of hypothetical restrictions suggest decreased ENDS use, increased cigarette use, and increased use of illicit markets. Studies of compliance with flavoured product restrictions that included ENDS found that 6–39% of stores sold restricted flavoured products post-restrictions. Online stores remain a potential source of restricted products.

Conclusion

Our findings highlight the need for additional research on the impacts of ENDS restrictions. Research should further evaluate the impact of restrictions on youth and adult use of nicotine and tobacco products in addition to the effects of restrictions in countries beyond the US to enable a robust consideration of the harm-benefit trade-off of restrictions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14440-x.

Expanding the E-Liquid Flavor Wheel: Classification of Emerging E-Liquid Flavors in Online Vape Shops

INTRODUCTION

Electronic cigarettes are the most popular tobacco product among U.S. youth, and over 80% of current youth users of e-cigarettes use flavored e-cigarettes, with fruit, mint/menthol, and candy/sweets being the most popular flavors. A number of new e-liquid flavors are currently emerging in the online e-cigarette market. Menthol and other flavored e-cigarettes could incentivize combustible tobacco smokers to transition to e-cigarette use.

METHODS

From February to May 2021, we scraped data of over 14,000 e-liquid products, including detailed descriptions of their flavors, from five national online vape shops. Building upon the existing e-liquid flavor wheel, we expanded the semantic databases (i.e., key terms) to identify flavors using WordNet-a major database for keyword matching and group discussion. Using the enriched databases, we classified 14,000+ e-liquid products into the following 11 main flavor categories: "fruit", "dessert/candy/sweets", "coffee/tea", "alcohol", "other beverages", "tobacco", "mint/menthol", "nuts", "spices/pepper", "other flavors", and "unspecified flavor".

RESULTS

We find that the most prominent flavor sold in the five online vape shop in 2021 was fruit flavored products, followed by dessert/candy/other sweets. Online vendors often label a product with several flavor profiles, such as fruit and menthol.

CONCLUSIONS

Given that online stores market products with multiple flavor profiles and most of their products contain fruit flavor, the FDA may have issued marketing denial orders to some of these products. It is important to further examine how online stores respond to the FDA flavor restrictions (e.g., compliance or non-compliance).

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.

Discussions of Flavored ENDS Sales Restrictions: Themes Related to Circumventing Policies on Reddit

Objective: To examine conversations among JUUL users on Reddit related to restrictions on flavored ENDS and the shifting policy landscape. Methods: Posts and comments (n = 166,169) between May 2019 and May 2020 on the subreddit r/JUUL were scraped using pushshift.io API. Keyword filters were used to identify texts discussing flavored ENDS products (n = 33,884 texts). These were further narrowed down to texts discussing flavor policy workaround strategies (n = 7429) and N-gram analysis was performed. Finally, findings from the N-gram analysis were triangulated through qualitative review of a separate sample of texts (n = 488) from the flavor policy-related posts and comments. Results: Overall activity on the subreddit r/JUUL peaked around the time of the EVALI outbreak (September 2019) and when FDA issued guidance restricting flavored ENDS product sales (January 2020). The N-gram analysis revealed an active discussion of banned products one can “still get” or “JUUL compatible” alternatives, including specific brands, brick and mortar locations, and specific flavors. Ten dominant themes emerged from the qualitative review, with some posts containing more than one theme. Conclusion: Many users turned to Reddit for information related to the shifting regulatory landscape concerning flavored ENDS. Discussions focused on both legal alternatives to banned products as well as illegal means of acquiring JUUL pods, including residual retail supply, online, and mail vendors.

Persistence and Attrition among Participants in a Multi-Page Online Survey Recruited via Reddit’s Social Media Network

Participant attrition is a major concern for the validity of longer or complex surveys. Unlike paper-based surveys, which may be discarded even if partially completed, multi-page online surveys capture responses from all completed pages until the time of abandonment. This can result in different item response rates, with pages earlier in the sequence showing more completions than later pages. Using data from a multi-page online survey administered to cohorts recruited on Reddit, this paper analyses the pattern of attrition at various stages of the survey instrument and examines the effects of survey length, time investment, survey format and complexity, and survey delivery on participant attrition. The participant attrition rate (PAR) differed between cohorts, with cohorts drawn from Reddit showing a higher PAR than cohorts targeted by other means. Common to all was that the PAR was higher among younger respondents and among men. Changes in survey question design resulted in the greatest rise in PAR irrespective of age, gender or cohort.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Peer-to-Peer Social Media Communication About Dietary Supplements Used for Weight Loss and Sports Performance Among Military Personnel: Pilot Content Analysis of 11 Years of Posts on Reddit

Background

Over 60% of military personnel in the United States currently use dietary supplements. Two types of dietary supplements, weight loss and sports performance (WLSP) supplements, are commonly used by military personnel despite the associated serious adverse effects such as dehydration and stroke.

Objective

To understand peer-to-peer communication about WLSP supplements among military personnel, we conducted a pilot study using the social media website, Reddit.

Methods

A total of 64 relevant posts and 243 comments from 2009 to 2019 were collected from 6 military subreddits. The posts were coded for year of posting, subreddit, and content consistent with the following themes: resources about supplement safety and regulation, discernability of supplement use through drug testing, serious adverse effects, brand names or identifiers, and reasons for supplement use.

Results

A primary concern posted by personnel who used supplements was uncertainty about the supplements that were not detectable on a drug test. Supplements to improve workout performance were the most frequently used.

Conclusions

Our pilot study suggests that military personnel may seek out peer advice about WLSP supplements on Reddit and spread misinformation about the safety and effectiveness of these products through this platform. Future directions for the monitoring of WLSP supplement use in military personnel are discussed.

Exploring food shopping behaviours through a study of Ottawa social media

This study explored the important attributes of the local food retail environments that residents from Ottawa, Ontario, Canada, used in recommending where to purchase fresh produce, including fruits and vegetables, in the Ottawa area. Drawing upon an approach originating in marketing and consumer research, qualitative thematic analysis was used to analyze 79 discussions from three social media platforms that occurred between 2015 and 2018. We identified three patterns of conversations about food shopping, characterized by participants describing important factors of their local retail food environments that shaped their recommendations for different retail food establishments: 1) Pleasant represented discussions where having a pleasurable food shopping experience was the main discussion point. 2) Thrifty discussions were marked primarily by economical management and discussed food shopping in pragmatic terms. 3) Compromise represented a group where discussions described needing to find a middle ground between affordability and quality. While not without limitations, our study was the first exploration of whether social media data could be useful for qualitatively evaluating local retail food environments. Our findings add to the conclusions of other researchers that social media data does not compromise on the breadth of views captured and can parallel findings from traditional methods. These findings have implications for nutrition researchers and practitioners who we encourage to consider social media discussion data in their work.

Analysis of a Vaping-Associated Lung Injury Outbreak through Participatory Surveillance and Archival Internet Data

The US Centers for Disease Control and Prevention alerted of a suspected outbreak of lung illness associated with using E-cigarette products in September 2019. At the time that the CDC published its alert little was known about the causes of the outbreak or who was at risk for it. Here we provide insights into the outbreak through analysis of passive reporting and participatory surveillance. We collected data about vaping habits and associated adverse reactions from four data sources pertaining to people in the USA: A participatory surveillance platform (YouVape), Reddit, Google Trends, and Bing. Data were analyzed to identify vaping behaviors and reported adverse events. These were correlated among sources and with prior reports. Data was obtained from 720 YouVape users, 4331 Reddit users, and over 1 million Bing users. Large geographic variation was observed across vaping products. Significant correlation was found among the data sources in reported adverse reactions. Models of participatory surveillance data found specific product and adverse reaction associations. Specifically, cannabidiol was found to be associated with fever, while tetrahydrocannabinol was found to be correlated with diarrhea. Our results demonstrate that utilization of different, complementary, online data sources provide a holistic view of vaping associated lung injury while augmenting traditional data sources.

We Post It, U Reddit: Exploring the Potential of Reddit for Health Interventions Targeting College Populations

Reddit is an anonymous social media platform that allows users to create, modify, share, and discuss content. While this platform is widely used by mainstream audiences, little research exists on how Redditors respond to health information when it appears in general, non-health specific forums called subreddits. Guided by media system dependency theory, the purpose of this study was to anonymously intervene on college subreddits to explore how Redditors interacted with messages about smoke-free policy compliance. Two messages were posted two weeks apart on ten college subreddits, yielding 370 comments (per thread range = 66-0) and 552 Karma points (per thread range = 123-0). A content analytic approach was employed, identifying eight content themes, and classifying message tone. The most popular themes were general smoking [n = 85], animosity toward smoke-free policies/compliance [n = 68], and smoke-free policy/compliance support [n = 65]). Most comments expressed a neutral tone [n = 196]. Data suggest that Redditors are willing to interact with health content on their college subreddits to varying degrees, especially if this content conforms to norms of the subreddit and/or platform. Implications from the findings suggest important considerations for use of Reddit as a future site for health interventions.

Both Nonsmoking Youth and Smoking Adults Like Sweet and Minty E-liquid Flavors More Than Tobacco Flavor

Smokers may reduce their health risk by switching to electronic cigarette (e-cigarette) use. As e-cigarettes are not harmless, concerns exist about e-cigarette use by nonsmokers and youth. E-liquids are available in many different flavors that increase sensory appeal. Flavor preferences may differ between user groups, which could open doors for product regulation. We investigated which e-liquid flavors are attractive to specific user groups by comparing liking between adolescent nonsmokers (n = 41; mean age 16.9 ± 0.8), young adult nonsmokers (n = 42; mean age 22.7 ± 1.7), and adult smokers (n = 56; mean age 39.7 ± 11.1). Participants smelled tobacco- (n = 6) and nontobacco (n = 24)-flavored e-liquids and rated liking on a 9-point labeled hedonic scale, and familiarity, overall intensity, perceived sweetness, perceived bitterness, and irritation of the odors on a 100-unit Visual Analog Scale. Mean liking ranged from 2.3 (whiskey) to 6.7 (peppermint). Within all groups, the typically sweet and minty flavors (e.g., wine gum, watermelon, peppermint, menthol) were liked significantly more than the tobacco-flavored e-liquids. The set of tobacco-flavored e-liquids was significantly, but slightly, less disliked by adult smokers (3.9 ± 0.2) than adolescent (3.1 ± 0.3) and young adult (3.4 ± 0.3) nonsmokers (P < 0.001). No between-group differences were observed for sweet and minty flavors. Liking correlated significantly positively with odor sweetness (R = 0.49) and familiarity (R = 0.48) and negatively with odor bitterness (R = -0.58), irritation (R = -0.47), and overall intensity (R = -0.27). Thus, sweet- and minty-flavored e-liquids are liked equally by young nonsmokers and adult smokers, and more than tobacco flavors. Banning all flavors except tobacco will likely reduce e-cigarette appeal; potentially more for young nonsmokers than adult smokers.

Vaping and Instagram: A Content Analysis of e-Cigarette Posts Using the Content Appealing to Youth (CAY) Index

The promotion of flavors, perceptions of "coolness," and general curiosity are characteristics of electronic nicotine delivery systems (ENDS) that have appealed to young adults. However, little is known about the characteristics of popular social media posts related to ENDS on the social media network, Instagram. Methods: Content analysis was performed using the Content Appealing to Youth (CAY) index. Over 700 posts were collected from August 2019 - December 2019 by searching the Instagram hashtags, #vape and #vapelife. Frequencies and percentages were calculated for each of the six major categories and 35 sub-categories. Results: Nearly all of the images were color photographs and 84% featured an ENDS device (mod) as the focal point. The style of the device was often matte (75%) in only one or two main colors (55%). Warnings about age restrictions and nicotine were included in 28% of images, but commonly used promotional tactics, such as humor, presence of vapor puffs, and flavors were rarely utilized. Conclusions: Instagram posts featuring ENDS are visually appealing and like cigarette packaging, may have the capacity to influence perceptions about the product. Since it is culturally normative for appealing images to be shared on Instagram, greater attention should be placed on media literacy skills to educate young adults about ENDS viewed on social media.

Analysis of potential associations of JUUL flavours with health symptoms based on user-generated data from Reddit

BACKGROUND

The rise of the popular e-cigarette, JUUL, has been partly attributed to various teen-friendly e-liquid flavours offered. However, the possible health risks associated with each e-liquid flavour still remain unclear. This research focuses on the possible associations between JUUL flavours and health symptoms using social media data from Reddit.

METHODS

Keyword filtering was used to obtain 5,746 JUUL flavour-related posts and 7927 health symptom-related posts from June 2015 to April 2019 from Reddit. Posts from September 2016 to April 2019 were used to conduct temporal analysis for nine health symptom categories and the 8 JUUL flavours. Finally, associations between the JUUL flavours and health symptom categories were examined on the user level using generalised estimating equation models.

RESULTS

According to our temporal analysis, Mango and Mint were the most discussed JUUL flavours on Reddit. Respiratory and throat symptoms were the most discussed health issues together with JUUL on Reddit over time. Respiratory symptoms had potential associations with the Mango, Mint and Fruit JUUL flavours. Digestive symptoms had a potential association with the Crème flavour, psychological symptoms had a potential association with the Cucumber flavour, and cardiovascular symptoms had a potential association with the tobacco flavours.

CONCLUSIONS

Mango and Mint were the two most mentioned JUUL flavours on Reddit. Certain JUUL flavours were more likely to be mentioned together with certain categories of health symptoms by the same Reddit users. Our findings could prompt further medical research into the health symptoms associated with different e-liquid flavours.

Characterizing Social Media Messages Related to Underage JUUL E-Cigarette Buying and Selling: Cross-Sectional Analysis of Reddit Subreddits

Background

Stopping the epidemic of e-cigarette use among youth has become the common goal of both regulatory authorities and health departments. JUUL is currently the most popular e-cigarette brand on the market. Young people usually obtain and exchange information about JUUL with the help of social media platforms. Along with the rising prevalence of JUUL, posts about underage JUUL buying and selling have appeared on social media platforms such as Reddit, which sharply increase the risk of minors being exposed to JUUL.

Objective

This study aims to analyze Reddit messages about JUUL buying and selling among the users of the UnderageJuul subreddit, and to further summarize the characteristics of those messages. The findings and insights can contribute to a better understanding of the patterns of underage JUUL use, and help public health officials provide timely education and guidance to minors who have intentions of accessing JUUL.

Methods

We used a novel cross-subreddit method to analyze the Reddit messages on 2 subreddits. From July 9, 2017, to January 7, 2018, we collected data from the UnderageJuul subreddit, which was created for underage JUUL use discussion. The data set included 716 threads, 2935 comments, and 844 Reddit users (ie, Redditors). We collected our second data set, comprising 23,840 threads and 162,106 comments posted between July 9, 2017, and January 8, 2019, from the JUUL subreddit. We conducted analyses including the following: (1) annotation of users with buying/selling intention, (2) posting patterns discovery and topic comparison, and (3) posting activeness observation of discovered Redditors. Term frequency–inverse document frequency and regular expression-enhanced keyword search methods were applied during the content analysis to extract the posting patterns. The public posting records of the discovered users on the JUUL subreddit during the year after the UnderageJuul subreddit was shut down were analyzed to determine whether they were still active and interested in obtaining JUUL.

Results

Our study revealed the following: (1) Among the 716 threads on the UnderageJuul subreddit, there were 214 threads related to JUUL sale and 168 threads related to JUUL purchase, which accounted for 53.5% (382/714) of threads. (2) Among the 844 Redditors of the UnderageJuul subreddit, 23.82% (201/844) of users were annotated with buying intention, and 21.10% (178/844) of users were annotated with selling intention. There were 34 users with buying/selling intention that self-reported as being <21 years old. (3) The most common key phrases used in selling threads were “WTS,” “want to sell,” “for sale,” and “selling” (154/214, 72.0%). The most common key phrases used in buying threads were “look for/get JUUL/pods” (58/168, 34.5%) and “WTB” (53/168, 31.5%). (4) The most important concern that UnderageJuul Redditors had in obtaining JUULs was the price (311/1306, 23.81%), followed by the delivery service (68/1306, 5.21%). (5) The most popular flavors among the users with buying/selling intention were mango, cucumber, and mint. The flavor preferences remained consistent on both subreddits. Adverse symptoms related to the mango flavor were reported by 3 users on the JUUL subreddit. (6) In total, 24.4% (49/201) of users wanted to buy JUULs and 46.6% (83/178) of users wanted to sell JUULs, including 11 self-reported underage users, who also participated in the discussions on the JUUL subreddit. (7) Within one year of the UnderageJuul subreddit shutting down, there were 40 users who continued to post 186 threads on the JUUL subreddit, including 10 threads indicating buying/selling willingness that were posted shortly after the UnderageJuul subreddit was closed.

Conclusions

There were overlapping users active in the JUUL and UnderageJuul subreddits. The buying/selling-related content appeared in multiple venues with certain posting patterns from July 9, 2017, to January 7, 2018. Such content might lead to a high risk of health problems for minors, such as nicotine addiction. Based on these findings, this study provided some insights and suggestions that might contribute to the decision-making processes of regulators and public health officials.

User Perceptions of Different Electronic Cigarette Flavors on Social Media: Observational Study

BACKGROUND

The number of electronic cigarette (e-cigarette) users has been increasing rapidly in recent years, especially among youth and young adults. More e-cigarette products have become available, including e-liquids with various brands and flavors. Various e-liquid flavors have been frequently discussed by e-cigarette users on social media.

OBJECTIVE

This study aimed to examine the longitudinal prevalence of mentions of electronic cigarette liquid (e-liquid) flavors and user perceptions on social media.

METHODS

We applied a data-driven approach to analyze the trends and macro-level user sentiments of different e-cigarette flavors on social media. With data collected from web-based stores, e-liquid flavors were classified into categories in a flavor hierarchy based on their ingredients. The e-cigarette-related posts were collected from social media platforms, including Reddit and Twitter, using e-cigarette-related keywords. The temporal trend of mentions of e-liquid flavor categories was compiled using Reddit data from January 2013 to April 2019. Twitter data were analyzed using a sentiment analysis from May to August 2019 to explore the opinions of e-cigarette users toward each flavor category.

RESULTS

More than 1000 e-liquid flavors were classified into 7 major flavor categories. The fruit and sweets categories were the 2 most frequently discussed e-liquid flavors on Reddit, contributing to approximately 58% and 15%, respectively, of all flavor-related posts. We showed that mentions of the fruit flavor category had a steady overall upward trend compared with other flavor categories that did not show much change over time. Results from the sentiment analysis demonstrated that most e-liquid flavor categories had significant positive sentiments, except for the beverage and tobacco categories.

CONCLUSIONS

The most updated information about the popular e-liquid flavors mentioned on social media was investigated, which showed that the prevalence of mentions of e-liquid flavors and user perceptions on social media were different. Fruit was the most frequently discussed flavor category on social media. Our study provides valuable information for future regulation of flavored e-cigarettes.

A Social Media Study on the Associations of Flavored Electronic Cigarettes With Health Symptoms: Observational Study

Background

In recent years, flavored electronic cigarettes (e-cigarettes) have become popular among teenagers and young adults. Discussions about e-cigarettes and e-cigarette use (vaping) experiences are prevalent online, making social media an ideal resource for understanding the health risks associated with e-cigarette flavors from the users’ perspective.

Objective

This study aimed to investigate the potential associations between electronic cigarette liquid (e-liquid) flavors and the reporting of health symptoms using social media data.

Methods

A dataset consisting of 2.8 million e-cigarette–related posts was collected using keyword filtering from Reddit, a social media platform, from January 2013 to April 2019. Temporal analysis for nine major health symptom categories was used to understand the trend of public concerns related to e-cigarettes. Sentiment analysis was conducted to obtain the proportions of positive and negative sentiment scores for all reported health symptom categories. Topic modeling was applied to reveal the topics related to e-cigarettes and health symptoms. Furthermore, generalized estimating equation (GEE) models were used to quantitatively measure potential associations between e-liquid flavors and the reporting of health symptoms.

Results

Temporal analysis showed that the Respiratory category was consistently the most discussed health symptom category among all categories related to e-cigarettes on Reddit, followed by the Throat category. Sentiment analysis showed higher proportions of positive sentiment scores for all reported health symptom categories, except for the Cancer category. Topic modeling conducted on all health-related posts showed that 17 of the top 100 topics were flavor related. GEE models showed different associations between the reporting of health symptoms and e-liquid flavor categories, for example, lower association of the Beverage flavors with Respiratory compared with other flavors and higher association of the Fruit flavors with Cardiovascular than other flavors.

Conclusions

This study identified different potential associations between e-liquid flavors and the reporting of health symptoms using social media data. The results of this study provide valuable information for further investigation of the health effects associated with different e-liquid flavors.

Location-Based Games and the COVID-19 Pandemic: An Analysis of Responses from Game Developers and Players

In early 2020, as a countermeasure to mitigate the spread of the COVID-19 pandemic, governments issued limitations on the movements of their citizens, cancelling social events and advising people to stay home. As location-based games (LBGs) have been found to influence human movement, their role during COVID-19 deserves closer inspection. Under regular circumstances, the very aim of these games is to motivate people to go out, explore and meet other people. However, during COVID-19, people were advised to do the exact opposite. To study how LBG developers and players reacted to the situation, we used the netnography research method utilizing three types of data: (1) COVID-19 related in-game changes made by seven popular LBG developers during March 2020; (2) social media reactions on 20 posts across three popular Pokémon GO subreddits; and (3) the raiding activity (collaborative play) in Pokémon GO in a Finnish municipality during February–May 2020. All observed LBGs made in-game changes due to COVID-19. The social media reactions showed overwhelming appreciation towards these changes, and two central second order themes arose: (1) LBGs have the ability to influence human movement during pandemics; and (2) people should be able to self-regulate their behaviour during COVID-19 independent of LBG influence. Surprisingly, recorded Pokémon GO player activity in Finland was more influenced by offered in-game rewards than the COVID-19 pandemic. Our findings have implications on how games and gamification can be used to direct human movement in situations such as COVID-19 where population-level interventions are needed.

Exposure and engagement with tobacco-related social media and associations with subsequent tobacco use among young adults: A longitudinal analysis

BACKGROUND

This study examines whether self-reported exposure to cigarette, e-cigarette, cigar, and hookah advertising, and engagement with pro-tobacco and anti-tobacco social media, are associated with past 30-day tobacco use one-year later, among young adults.

METHODS

Data were from two waves of the Marketing and Promotions Across Colleges in Texas study, a multi-wave study of two- and four-year Texas college students (N = 3947; M age = 23.3, SD = 2.3; 64% female; 35% white, 31% Hispanic, 19% Asian, 8% African-American/black, 7% multi-racial/other) from 24 urban-area schools. Multiple logistic regression examined longitudinal associations between recall of exposure and engagement at baseline (wave 6, spring 2017) and tobacco use at one-year follow-up (wave 7, spring 2018), accounting for baseline demographic characteristics and tobacco use.

RESULTS

Self-reported exposure to and engagement with tobacco-related social media were significantly associated with past 30-day use of e-cigarettes, cigars, and hookah at one-year follow up; engagement was also associated with cigarette use. Controlling for other social media, exposure to any product advertising via Reddit increased risk for e-cigarette use (AOR = 1.92 [95% CI: 1.17-3.14]). Pinterest exposure increased risk for cigar use (2.92 [1.24-6.85]). Snapchat exposure increased risk for hookah use (2.94 [1.70-5.11]). Pro-tobacco engagement increased risk for future use of all products (1.77 [1.29-2.42]). Anti-tobacco engagement increased risk for use of cigars (1.59 [1.12-2.27]) and hookah (1.69 [1.27-2.25]).

CONCLUSIONS

Findings demonstrate that encountering tobacco-related social media is an important risk factor for future tobacco use among young people. Social media should be a focus of federal regulation, counter-marketing and health communication campaigns, and intervention.

Insights on electronic cigarette products from reviews on the Reddit forum

INTRODUCTION

E-cigarette devices and their component parts are continuously evolving. Little is known about the product design features that may increase the appeal of e-cigarette use, ultimately affecting continuation of use. Product reviews have been described as useful in helping to forecast the popularity of products, and online reviews have become an important channel of product information. This study analyzed e-cigarette product reviews to attempt to arrive at a greater understanding of the features of e-cigarette products that may make them appealing to current users.

METHODS

Data included 248 product reviews found on a popular e-cigarette-related discussion site of Reddit from 10 April 2017 to 12 November 2018. For this study, we examined the sub-sections relating to the positive features (PFs) and negative features (NFs) of the product, found in each review. Common themes were identified and coded.

RESULTS

There were 2929 comments on PFs (average 12 per product), and 1003 on NFs (average 4 per product). Commonly found in the reviews were the ten themes: build quality, color, tip model, battery quality, price, screw quality, power mode performance, coil performance, temperature control performance, and tank quality.

CONCLUSIONS

Findings suggest e-cigarette users expect well-made devices and have developed ways to discriminate between products that perform well from those that do not. Findings suggest that the control of price and design features of e-cigarette products (e.g. color, size, voltage, wattage, coils) warrants consideration for future research and policies addressing e-cigarette use.

An E-Liquid Flavor Wheel: A Shared Vocabulary Based on Systematically Reviewing E-Liquid Flavor Classifications in Literature

Introduction

E-liquids are available in a high variety of flavors. A systematic classification of e-liquid flavors is necessary to increase comparability of research results. In the food, alcohol, and fragrance industry, flavors are classified using flavor wheels. We systematically reviewed literature on flavors related to electronic cigarette use, to investigate how e-liquid flavors have been classified in research, and propose an e-liquid flavor wheel to classify e-liquids based on marketing descriptions.

Methods

The search was conducted in May 2017 using PubMed and Embase databases. Keywords included terms associated with electronic cigarette, flavors, liking, learning, and wanting in articles. Results were independently screened and reviewed. Flavor categories used in the articles reviewed were extracted.

Results

Searches yielded 386 unique articles of which 28 were included. Forty-three main flavor categories were reported in these articles (eg, tobacco, menthol, mint, fruit, bakery/dessert, alcohol, nuts, spice, candy, coffee/tea, beverages, chocolate, sweet flavors, vanilla, and unflavored). Flavor classifications of e-liquids in literature showed similarities and differences across studies. Our proposed e-liquid flavor wheel contains 13 main categories and 90 subcategories, which summarize flavor categories from literature to find a shared vocabulary. For classification of e-liquids using our flavor wheel, marketing descriptions should be used.

Conclusions

We have proposed a flavor wheel for classification of e-liquids. Further research is needed to test the flavor wheels’ empirical value. Consistently classifying e-liquid flavors using our flavor wheel in research (eg, experimental, marketing, or qualitative studies) minimizes interpretation differences and increases comparability of results.

Implications

We reviewed e-liquid flavors and flavor categories used in research. A large variation in the naming of flavor categories was found and e-liquid flavors were not consistently classified. We developed an e-liquid flavor wheel and provided a guideline for systematic classification of e-liquids based on marketing descriptions. Our flavor wheel summarizes e-liquid flavors and categories used in literature in order to create a shared vocabulary. Applying our flavor wheel in research on e-liquids will improve data interpretation, increase comparability across studies, and support policy makers in developing rules for regulation of e-liquid flavors.

How Smoking Advocates are Connected Online: An Examination of Online Social Relationships Supporting Smoking Behaviors

Social media platforms can facilitate online relationship formation among people who engage in risky health behavior such as smoking or unprotected sex. The purpose of this study is to gain a better understanding of how individuals who promote risky health behavior are connected with similar others on social media. Focusing on smoking behavior, this study investigates the theoretical mechanisms that drive social connections among pro-smoking users, and examines an empirical instance of one such network structure on Twitter. Consistent with the social identity framework, the study finds that pro-smoking networks manifest higher stance homophily (pro-smoking vs. anti-smoking) and higher network cohesion than anti-smoking networks. Different from the hypothesis, however, the result shows lower network exclusivity than anti-smoking networks. Most pro-smoking users who had social ties with anti-smoking users were found to be individuals rather than pressure groups or organizations. Bridging users on both sides tended to be linked to pressure groups. This paper concluded with discussion of implications of the current findings.

A content analysis of the promotional strategies employed by e-cigarette brands on Twitter

Cigarette smoking in the U.S. is declining, but e-cigarette (e-cig) use is rapidly expanding. E-cig brands utilize social media for promotion and have the autonomy to disseminate messages that encourage the use of their products. The current study categorized the most frequent strategies among popular e-cig brands on Twitter. A content analysis of over 1800 tweets was performed based on Philip Morris brand personality characteristics. Most tweets emphasized e-cigs' economic value (24.2%) and normalized their use by portraying e-cigs as "cool" (23.1%). E-cig brands are employing similar strategies as tobacco companies and easily connecting to young adults through social media.

In Vitro Consequences of Electronic-Cigarette Flavoring Exposure on the Immature Lung

Background: The developing lung is uniquely susceptible and may be at increased risk of injury with exposure to e-cigarette constituents. We hypothesize that cellular toxicity and airway and vascular responses with exposure to flavored refill solutions may be altered in the immature lung. Methods: Fetal, neonatal, and adult ovine pulmonary artery smooth muscle cells (PASMC) were exposed to popular flavored nicotine-free e-cigarette refill solutions (menthol, strawberry, tobacco, and vanilla) and unflavored solvents: propylene glycol (PG) or vegetable glycerin (VG). Viability was assessed by lactate dehydrogenase assay. Brochodilation and vasoreactivity were determined on isolated ovine bronchial rings (BR) and pulmonary arteries (PA). Results: Neither PG or VG impacted viability of immature or adult cells; however, exposure to menthol and strawberry flavored solutions increased cell death. Neonatal cells were uniquely susceptible to menthol flavoring-induced toxicity, and all four flavorings demonstrated lower lethal doses (LD50) in immature PASMC. Exposure to flavored solutions induced bronchodilation of neonatal BR, while only menthol induced airway relaxation in adults. In contrast, PG/VG and flavored solutions did not impact vasoreactivity with the exception of menthol-induced relaxation of adult PAs. Conclusion: The immature lung is uniquely susceptible to cellular toxicity and altered airway responses with exposure to common flavored e-cigarette solutions.

Underage JUUL Use Patterns: Content Analysis of Reddit Messages

Background

The popularity of JUUL (an e-cigarette brand) among youth has recently been reported in news media and academic papers, which has raised great public health concerns. Little research has been conducted on the age distribution, geographic distribution, approaches to buying JUUL, and flavor preferences pertaining to underage JUUL users.

Objective

The aim of this study was to analyze social media data related to demographics, methods of access, product characteristics, and use patterns of underage JUUL use.

Methods

We collected publicly available JUUL-related data from Reddit. We extracted and summarized the age, location, and flavor preference of subreddit UnderageJuul users. We also compared common and unique users between subreddit UnderageJuul and subreddit JUUL. The methods of purchasing JUULs were analyzed by manually examining the content of the Reddit threads.

Results

A total of 716 threads and 2935 comments were collected from the subreddit UnderageJuul before it was shut down. Most threads did not mention a specific age, but ages ranged from 13 years to greater than 21 years in those that did. Mango, mint, and cucumber were the most popular among the 7 flavors listed on JUUL’s official website, and 336 subreddit UnderageJuul threads mentioned 7 discreet approaches to circumvent relevant legal regulations to get JUUL products, the most common of which was purchasing JUUL from other Reddit users (n=181). Almost half of the UnderageJuul users (389/844, 46.1%) also participated in discussions on the main JUUL subreddit and sought information across multiple Reddit forums. Most (64/74, 86%) posters were from large metropolitan areas.

Conclusions

The subreddit UnderageJuul functioned as a forum to explore methods of obtaining JUUL and to discuss and recommend specific flavors before it was shut down. About half of those using UnderageJuul also used the more general JUUL subreddit, so a forum still exists where youths can attempt to share information on how to obtain JUUL and other products. Exploration of such social media data in real time for rapid public health surveillance could provide early warning for significant health risks before they become major public health threats.

The impact of flavors, health risks, secondhand smoke and prices on young adults' cigarette and e-cigarette choices: a discrete choice experiment

AIMS

To estimate young adults' preferences for cigarettes and e-cigarettes, and how preferences vary by policy-relevant factors. A related aim was to provide information on potential substitution/complementarity across cigarettes and e-cigarettes ahead of policy selection.

DESIGN

An online discrete choice experiment (DCE) in which respondents chose their preferred option among cigarettes, two types of e-cigarettes (disposable/reusable) and 'none'. Each cigarette-type was characterized by policy-relevant attributes: flavors, short-term health risks to self, secondhand smoke risks and price. A latent class model identified smoking types that respond differently to these.

SETTING

US tobacco market.

PARTICIPANTS

A total of 2003 young adults (aged 18-22 years) who ever tried either cigarettes or e-cigarettes, recruited via the survey platform Qualtrics, matched to the 2015 National Health Interview Survey by age, gender, education and census region.

MEASUREMENTS

Respondents' DCE choices.

FINDINGS

Young adults fell into two broad categories. One latent group, termed 'prefer smoking group', preferred cigarettes and another, 'prefer vaping group', preferred e-cigarettes. The 'prefer smoking group' preferred lower prices and lower health harms more than other attributes. The 'prefer vaping group' valued these, although price less intensely, and valued health and fruit/candy flavors more.

CONCLUSION

Banning all flavors in cigarettes and e-cigarettes might improve the health of young adults who ever tried either cigarettes or e-cigarettes. Young adult ever-triers might be deterred from smoking by increasing cigarette prices and encouraged to switch to e-cigarettes by reducing the health harms of e-cigarettes. Reducing health harms of e-cigarettes could also make the 'prefer vaping group' less likely to quit, resulting in increased health harm.

Promotion of Vape Tricks on YouTube: Content Analysis

Background

The ability to perform vape tricks (ie, blowing large vapor clouds or shapes like rings) using e-cigarettes appeals to youth. Vape tricks are promoted on social media, but the promotion of vape tricks on social media is not well understood.

Objective

The aim of this study was to examine how vape tricks were promoted on YouTube to youth.

Methods

Videos on vape tricks that could be accessed by underage youth were identified. The videos were coded for number of views, likes, dislikes, and content (ie, description of vape tricks, e-cigarette devices used for this purpose, video sponsors [private or industry], brand marketing, and contextual characteristics [eg, model characteristics, music, and profanity]).

Results

An analysis of 59 sample videos on vape tricks identified 25 distinct vape tricks. These videos had more likes than dislikes (11 to 1 ratio) and a 32,017 median view count. 48% (28/59) of the videos were posted by industry accounts (27% [16/59] provaping organizations, 15% [9/59] online shops, and 3% [2/59] vape shops) and 53% by private accounts (55% [17/31] private users, 26% [8/31] vape enthusiasts, and 19% [6/31] YouTube influencers); 53% (31/59) of the videos promoted a brand of e-cigarette devices, e-liquids, or online/vape shops, and 99% of the devices used for vape tricks were advanced generation devices. The models in the videos were 80.2% (160/198) male, 51.5% white (102/198), and 61.6% (122/198) aged 18 to 24 years; 85% (50/59) of the videos had electronic dance music and hip hop, and 32% (19/59) had profanity.

Conclusions

Vape trick videos on YouTube, about half of which were industry sponsored, were accessible to youth. Restrictions of e-cigarette marketing on social media, such as YouTube, are needed.

A longitudinal analysis of electronic cigarette forum participation

Electronic cigarette (e-cigarette) Internet forums are social networking websites that allow members around the world to share information and personal experiences about e-cigarettes. However, little is known about their popularity and reach. This longitudinal study investigated indicators of participation (membership, number of discussion boards, and number of message posts) in 77 e-cigarette forums from February 2016 to January 2017. Autoregressive time-series analyses were used to assess monthly changes in participation among small (<1000 members), medium (1000-5000 members), and large (>5000 members) forums that were active at all 12 observation time points. Paired sample t-tests were conducted to compare changes in participation before and after the U.S. Food and Drug Administration announced the regulation of e-cigarettes. Analyses revealed significant and consistent increases in forum membership (R²s > 0.72; ps < 0.01), discussion boards (R²s > 0.97; ps < 0.001), and message posts (R²s > 0.96; ps < 0.001) across all forum sizes during the 12-month period. No differences were found in participation indicators pre- and post-regulation announcement. E-cigarette forums provide real-time information on the levels of participation over time and therefore may be an important platform to study interactions among consumers and how these interactions shape e-cigarette knowledge, attitudes and use behaviors.

Electronic cigarette usage patterns: a case study combining survey and social media data

Objective

To identify who were social media active e-cigarette users, to compare the use patterns from both survey and social media data for data triangulation, and to jointly use both datasets to conduct a comprehensive analysis on e-cigarette future use intentions.

Materials and Methods

We jointly used an e-cigarette use online survey (n = 5132) and a social media dataset. We conducted analysis from 3 different perspectives. We analyzed online forum participation patterns using survey data. We compared e-cigarette use patterns, including brand and flavor types, ratings, and purchase approaches, between the 2 datasets. We used logistic regression to study intentions to use e-cigarettes using both datasets.

Results

Male and younger e-cigarette users were the most likely to participate in e-cigarette-related discussion forums. Forum active survey participants were hardcore vapers. The e-cigarette use patterns were similar in the online survey data and the social media data. Intention to use e-cigarettes was positively related to e-liquid ratings and flavor ratings. Social media provided a valuable source of information on users' ratings of e-cigarette refill liquids.

Discussion

For hardcore vapers, social media data were consistent with online survey data, which suggests that social media may be useful to study e-cigarette use behaviors and can serve as a useful complement to online survey research. We proposed an innovative framework for social media data triangulation in public health studies.

Conclusion

We illustrated how social media data, combined with online survey data, can serve as a new and rich information source for public health research.

A content analysis of JUUL discussions on social media: Using Reddit to understand patterns and perceptions of JUUL use

BACKGROUND

JUUL, an electronic cigarette, is estimated to occupy 50% of the e-cigarette market and appears to be particularly common among youth. However, there is little research on perceptions of JUUL. The aim of the current study was to examine posts on Reddit specific to JUUL and youth to better understand the context and perceptions of JUUL use.

METHODS

This content analysis utilized social media discussions posted between January 2015-May 2017. Public posts on Reddit, a social media platform, were gathered and coded. Posters of discussions relevant to both JUUL and youth were included for analysis.

RESULTS

364 posts were included for quantitative content analysis. Posts were mixed in terms of polarity with many (41.1%) including positive and negative language regarding JUUL. In terms of polarity of youth use, 60% of posts showed negative perceptions of youth use. Among posts by youth, only 37% showed negative perceptions of youth use. Posts included a variety of reasons for using JUUL with the most frequent reason being the popularity of JUUL (34.2%) followed by using it to quit smoking (23.3%) and to feel a buzz (20.2%). Age restrictions were the most common barrier to use.

CONCLUSIONS

Posters generally had a nuanced perception of JUUL and identified both positive and negative aspects. Interestingly, while primary reasons for youth use indicate the strong influence of social norms, barriers to use suggest that public health interventions such as age restrictions may curb youth use. Findings can inform prevention efforts and important factors for JUUL initiation.

A qualitative exploration of information-seeking by electronic nicotine delivery systems (ENDS) users in New Zealand

OBJECTIVES

Given recent increases in awareness and uptake of electronic nicotine delivery systems (ENDS), we aimed to explore ENDS users' information needs and search behaviours and whether information gaps exist.

DESIGN

Qualitative study using semistructured interviews that probed participants' smoking behaviours and ENDS use; data in this study examine ENDS information-seeking behaviours. We used qualitative description to analyse interview transcripts.

PARTICIPANTS AND SETTING

We recruited 39 current ENDS users (20 dual users and 19 exclusive ENDS users who reported having previously smoked cigarettes regularly) aged 18 and over, from three urban centres in New Zealand.

RESULTS

Several participants used Google to search for information on ENDS' health effects, but described the material they retrieved as vague or contradictory. Some interpreted the absence of information on long-term health effects as evidence ENDS did not pose potential health risks, and several perceived e-liquids as benign. Many relied on information sourced from other ENDS users, gleaned from online forums, YouTube or from discussions with friends and acquaintances; these sources typically presented ENDS positively. Several participants found specialist ENDS retailers provided valuable advice; non-specialist store staff generally lacked detailed product knowledge and sometimes offered inaccurate information.

CONCLUSION

People seeking information on ENDS' health effects are more likely to retrieve recommendations, product reviews and endorsements from online sources or through exchanges with other users, than they are to find scientific data. Health authorities could help meet potential users' information needs by, first, creating and frequently updating objective lay summaries of the latest scientific evidence; second, by mandating licensing for retailers with guidelines to disclose uncertainty over ENDS' efficacy for cessation and longer-term health effects, and the need for complete substitution of ENDS for combustible cigarettes among those who use these products.

Understanding Users' Vaping Experiences from Social Media: Initial Study Using Sentiment Opinion Summarization Techniques

Background

E-liquid is one of the main components in electronic nicotine delivery systems (ENDS). ENDS review comments could serve as an early warning on use patterns and even function to serve as an indicator of problems or adverse events pertaining to the use of specific e-liquids—much like types of responses tracked by the Food and Drug Administration (FDA) regarding medications.

Objective

This study aimed to understand users’ “vaping” experience using sentiment opinion summarization techniques, which can help characterize how consumers think about specific e-liquids and their characteristics (eg, flavor, throat hit, and vapor production).

Methods

We collected e-liquid reviews on JuiceDB from June 27, 2013 to December 31, 2017 using its public application programming interface. The dataset contains 27,070 reviews for 8058 e-liquid products. Each review is accompanied by an overall rating and a set of 4 aspect ratings of an e-liquid, each on a scale of 1-5: flavor accuracy, throat hit, value, and cloud production. An iterative dichotomiser 3 (ID3)-based influential aspect analysis model was adopted to learn the key elements that impact e-liquid use. Then, fine-grained sentiment analysis was employed to mine opinions on various aspects of vaping experience related to e-liquids.

Results

We found that flavor accuracy and value were the two most important aspects that affected users’ sentiments toward e-liquids. Of reviews in JuiceDB, 67.83% (18,362/27,070) were positive, while 12.67% (3430/27,070) were negative. This indicates that users generally hold positive attitudes toward e-liquids. Among the 9 flavors, fruity and sweet were the two most popular. Great and sweet tastes, reasonable value, and strong throat hit made users satisfied with fruity and sweet flavors, whereas “strange” tastes made users dislike those flavors. Meanwhile, users complained about some e-liquids’ steep or expensive prices, bad quality, and harsh throat hit. There were 2342 fruity e-liquids and 2049 sweet e-liquids. There were 55.81% (1307/2342) and 59.83% (1226/2049) positive sentiments and 13.62% (319/2342) and 12.88% (264/2049) negative sentiments toward fruity e-liquids and sweet e-liquids, respectively. Great flavors and good vapors contributed to positive reviews of fruity and sweet products. However, bad tastes such as “sour” or “bitter” resulted in negative reviews. These findings can help businesses and policy makers to further improve product quality and formulate effective policy.

Conclusions

This study provides an effective mechanism for analyzing users’ ENDS vaping experience based on sentiment opinion summarization techniques. Sentiment opinions on aspect and products can be found using our method, which is of great importance to monitor e-liquid products and improve work efficiency.

New Tobacco and Tobacco-Related Products: Early Detection of Product Development, Marketing Strategies, and Consumer Interest

Background

A wide variety of new tobacco and tobacco-related products have emerged on the market in recent years.

Objective

To understand their potential implications for public health and to guide tobacco control efforts, we have used an infoveillance approach to identify new tobacco and tobacco-related products.

Methods

Our search for tobacco(-related) products consists of several tailored search profiles using combinations of keywords such as “e-cigarette” and “new” to extract information from almost 9000 preselected sources such as websites of online shops, tobacco manufacturers, and news sites.

Results

Developments in e-cigarette design characteristics show a trend toward customization by possibilities to adjust temperature and airflow, and by the large variety of flavors of e-liquids. Additionally, more e-cigarettes are equipped with personalized accessories, such as mobile phones, applications, and Bluetooth. Waterpipe products follow the trend toward electronic vaping. Various heat-not-burn products were reintroduced to the market.

Conclusions

Our search for tobacco(-related) products was specific and timely, though advances in product development require ongoing optimization of the search strategy. Our results show a trend toward products resembling tobacco cigarettes vaporizers that can be adapted to the consumers’ needs. Our search for tobacco(-related) products could aid in the assessment of the likelihood of new products to gain market share, as a possible health risk or as an indicator for the need on independent and reliable information of the product to the general public.

Influence of Flavors on the Propagation of E-Cigarette-Related Information: Social Media Study

Background

Modeling the influence of e-cigarette flavors on information propagation could provide quantitative policy decision support concerning smoking initiation and contagion, as well as e-cigarette regulations.

Objective

The objective of this study was to characterize the influence of flavors on e-cigarette–related information propagation on social media.

Methods

We collected a comprehensive dataset of e-cigarette–related discussions from public Pages on Facebook. We identified 11 categories of flavors based on commonly used categorizations. Each post’s frequency of being shared served as a proxy measure of information propagation. We evaluated a set of regression models and chose the hurdle negative binomial model to characterize the influence of different flavors and nonflavor control variables on e-cigarette–related information propagation.

Results

We found that 5 flavors (sweet, dessert & bakery, fruits, herbs & spices, and tobacco) had significantly negative influences on e-cigarette–related information propagation, indicating the users’ tendency not to share posts related to these flavors. We did not find a positive significance of any flavors, which is contradictory to previous research. In addition, we found that a set of nonflavor–related factors were associated with information propagation.

Conclusions

Mentions of flavors in posts did not enhance the popularity of e-cigarette–related information. Certain flavors could even have reduced the popularity of information, indicating users’ lack of interest in flavors. Promoting e-cigarette–related information with mention of flavors is not an effective marketing approach. This study implies the potential concern of users about flavorings and suggests a need to regulate the use of flavorings in e-cigarettes.

A systematic review of consumer preference for e-cigarette attributes: Flavor, nicotine strength, and type

Objective

Systematic review of research examining consumer preference for the main electronic cigarette (e-cigarette) attributes namely flavor, nicotine strength, and type.

Method

A systematic search of peer-reviewed articles resulted in a pool of 12,933 articles. We included only articles that meet all the selection criteria: (1) peer-reviewed, (2) written in English, and (3) addressed consumer preference for one or more of the e-cigarette attributes including flavor, strength, and type.

Results

66 articles met the inclusion criteria for this review. Consumers preferred flavored e-cigarettes, and such preference varied with age groups and smoking status. We also found that several flavors were associated with decreased harm perception while tobacco flavor was associated with increased harm perception. In addition, some flavor chemicals and sweeteners used in e-cigarettes could be of toxicological concern. Finally, consumer preference for nicotine strength and types depended on smoking status, e-cigarette use history, and gender.

Conclusion

Adolescents could consider flavor the most important factor trying e-cigarettes and were more likely to initiate vaping through flavored e-cigarettes. Young adults overall preferred sweet, menthol, and cherry flavors, while non-smokers in particular preferred coffee and menthol flavors. Adults in general also preferred sweet flavors (though smokers like tobacco flavor the most) and disliked flavors that elicit bitterness or harshness. In terms of whether flavored e-cigarettes assisted quitting smoking, we found inconclusive evidence. E-cigarette users likely initiated use with a cigarette like product and transitioned to an advanced system with more features. Non-smokers and inexperienced e-cigarettes users tended to prefer no nicotine or low nicotine e-cigarettes while smokers and experienced e-cigarettes users preferred medium and high nicotine e-cigarettes. Weak evidence exists regarding a positive interaction between menthol flavor and nicotine strength.

Effect of Flavors and Modified Risk Messages on E-cigarette Abuse Liability

Objectives

To measure e-cigarettes' abuse liability compared to conventional tobacco cigarettes under flavor and message conditions amenable to regulation.

Methods

Two studies used 2×2 within-subjects designs with factors of e-cigarette flavor (Study 1: tobacco vs. menthol; Study 2: cherry vs. unflavored) and message (Study 1: reduced harm vs. no message; Study 2: reduced exposure to carcinogens vs. no message) with cigarette smokers (N(total) = 36). Linear mixed effects models assessed abuse liability for tobacco products. Outcomes included the price after which consumption is zero (the maximum amount participants would pay for a tobacco product) from the multiple choice procedure (MCP) and cigarette purchase task (CPT) and demand elasticity (price sensitivity) from the CPT.

Results

In the MCP, the price where consumption reached zero was significantly lower in all e-cigarette conditions except tobacco flavor (message or no message) compared to cigarettes (p < .05 each). Demand elasticity was significantly higher for menthol/no message and unflavored/reduced exposure message conditions relative to cigarettes (p < .05 each).

Conclusions

Flavors and modified risk messages included with e-cigarettes may affect e-cigarette abuse liability among smokers, suggesting regulatory pathways to influence demand for conventional and alternative tobacco products.

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

PURPOSE

Little is known about the nature and extent of adolescents' exposure to tobacco- and e-cigarette-related communications on social media. In this study, we describe the prevalence and correlates of youth exposure and engagement with tobacco- and e-cigarette-related social media.

METHODS

Data are from the baseline survey of the Texas Adolescent Tobacco and Marketing Surveillance system, a cross-sectional sample of sixth, eighth, and 10th graders (n = 3907, N = 461,097). Weighted logistic regression models were used to examine associations between demographic characteristics, sensation seeking, tobacco use, and exposure and engagement with tobacco-related social media.

RESULTS

Overall, 52.5% of students reported exposure to tobacco-related social media in the past month, whereas < 6% reported engagement. Exposure and some forms of engagement were more common among high school students, girls, those with friends who use tobacco, and high sensation seekers (p < .05). The odds of exposure were significantly higher among students susceptible to combustible tobacco (adjusted odds ratio [AOR] = 1.71, p < .05), e-cigarettes (AOR = 2.10, p < .01), and both combustible tobacco and e-cigarettes (AOR = 2.24, p < .001). The odds of engaging with social media was higher among those who were susceptible to, had ever, or currently use both combustible tobacco and e-cigarettes (AOR = 2.10-3.46, p < .05).

CONCLUSIONS

About 1 in every 2 adolescents in Texas are exposed to tobacco-related social media. Adolescents who are susceptible to or use e-cigarettes and/or combustible tobacco are exposed to and engage with tobacco-related social media more than their peers. Social media appears to be an important venue when targeting vulnerable youth in prevention campaigns.

Pilot Experiment: The Effect of Added Flavorants on the Taste and Pleasantness of Mixtures of Glycerol and Propylene Glycol

Introduction

The US Food and Drug Administration banned most "sweet" flavorants for use in cigarettes due to the concern that sweet flavors appeal to young, beginning smokers. However, many of the same flavors, including fruity and confection-associated aromas (e.g. vanilla) are still used in e-cigarettes. Sweet flavors may have a number of effects, including enhancement of the taste of other ingredients. The current work focused on the impact of model flavorants on the taste of a mixture of propylene glycol and vegetable glycerine, solvents used in most e-cigarettes and related products.

Methods

A device delivered mixtures of propylene glycol and vegetable glycerine into the mouth in parallel with puffs of clean air (control) or odorized air. Aromas included two "fruity" esters ("pineapple" and "banana"), two confection-associated aromas ("vanilla" and "caramel/malty"), menthol (not a "sweet" aroma, but commonly used in e-cigarettes), and a "burnt" aroma not expected enhance flavor. Twenty young adults, aged 18-25, rated the sweetness, bitterness, and pleasantness of all stimuli (within-subjects design).

Results

Both fruity aromas significantly enhanced sweetness, both confection-associated aromas significantly enhanced pleasantness, and the caramel/malty aroma significantly reduced bitterness. Menthol and the "burnt" aroma had no measurable effects on the taste of solvent mixtures.

Conclusion

Some flavorants modulated the taste of solvents commonly used in e-cigarettes in ways consistent with an enhanced sensory profile.

Implications

If similar effects occur in actual products, improved flavor profiles could facilitate continued use, particularly in non-smokers experimenting with e-cigarettes and related products.

Mining online e-liquid reviews for opinion polarities about e-liquid features

BACKGROUND

In recent years, the emerging electronic cigarette (e-cigarette) marketplace has developed prosperously all over the world. By analyzing online e-liquid reviews, we seek to identify the features attracting users.

METHODS

We collected e-liquid reviews from one of the largest online e-liquid review websites and extracted the e-liquid features by keywords. Then we used sentiment analysis to classify the features into two polarities: positive and negative. The positive sentiment ratio of a feature reflects the e-cigarette users' preference on this feature.

RESULTS

The popularity and preference of e-liquid features are not correlated. Nuts and cream are the favorite flavor categories, while fruit and cream are the most popular categories. The top mixed flavors are preferable to single flavors. Fruit and cream categories are most frequently mixed with other flavors. E-cigarette users are satisfied with cloud production, but not satisfied with the ingredients and throat hit.

CONCLUSIONS

We identified the flavors that e-cigarette users were satisfied with, and we found the users liked e-cigarette cloud production. Therefore, flavors and cloud production are potential factors attracting new users.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

Identifying Topics for E-Cigarette User-Generated Contents: A Case Study From Multiple Social Media Platforms

Background

Electronic cigarette (e-cigarette) is an emerging product with a rapid-growth market in recent years. Social media has become an important platform for information seeking and sharing. We aim to mine hidden topics from e-cigarette datasets collected from different social media platforms.

Objective

This paper aims to gain a systematic understanding of the characteristics of various types of social media, which will provide deep insights into how consumers and policy makers effectively use social media to track e-cigarette-related content and adjust their decisions and policies.

Methods

We collected data from Reddit (27,638 e-cigarette flavor-related posts from January 1, 2011, to June 30, 2015), JuiceDB (14,433 e-juice reviews from June 26, 2013 to November 12, 2015), and Twitter (13,356 “e-cig ban”-related tweets from January, 1, 2010 to June 30, 2015). Latent Dirichlet Allocation, a generative model for topic modeling, was used to analyze the topics from these data.

Results

We found four types of topics across the platforms: (1) promotions, (2) flavor discussions, (3) experience sharing, and (4) regulation debates. Promotions included sales from vendors to users, as well as trades among users. A total of 10.72% (2,962/27,638) of the posts from Reddit were related to trading. Promotion links were found between social media platforms. Most of the links (87.30%) in JuiceDB were related to Reddit posts. JuiceDB and Reddit identified consistent flavor categories. E-cigarette vaping methods and features such as steeping, throat hit, and vapor production were broadly discussed both on Reddit and on JuiceDB. Reddit provided space for policy discussions and majority of the posts (60.7%) holding a negative attitude toward regulations, whereas Twitter was used to launch campaigns using certain hashtags. Our findings are based on data across different platforms. The topic distribution between Reddit and JuiceDB was significantly different (P<.001), which indicated that the user discussions focused on different perspectives across the platforms.

Conclusions

This study examined Reddit, JuiceDB, and Twitter as social media data sources for e-cigarette research. These mined findings could be further used by other researchers and policy makers. By utilizing the automatic topic-modeling method, the proposed unified feedback model could be a useful tool for policy makers to comprehensively consider how to collect valuable feedback from social media.

Flavored E-cigarette Use and Cigarette Smoking Susceptibility among Youth

Objectives

Research indicates youth e-cigarette use may lead to the use of conventional cigarettes, but the specific effects of flavored e-cigarettes-which greatly appeal to youth-are unknown. Therefore, this study examines how flavored e-cigarette use predicts cigarette smoking susceptibility among youth non-smokers.

Methods

We used 2014 National Youth Tobacco Survey to explore the relationship between current e-cigarette use (non-use, flavored and plain e-cigarette use) and smoking susceptibility among 18,392 youth non-smokers (ages 11-18 years).

Results

Overall, 2.2% and 2.1% of non-smoking youth currently used plain and flavored e-cigarettes. Compared to 30.0% of non-users, 61.1% and 74.1% of plain and flavored e-cigarette users reported smoking susceptibility. Flavored e-cigarette users were more likely to be susceptible than plain e-cigarette users (AOR=1.7, p< .001) and non-users (AOR=3.8, p< .0001). The magnitude of the relationship between flavored e-cigarette use and smoking susceptibility was significantly higher for females (AOR=6.5, p< .01) than males (AOR=2.5, p< .01).

Conclusions

Flavored more so than plain e-cigarette use is strongly associated with smoking susceptibility among non-smoking youth. Flavored e-cigarettes are recruiting females and those with low smoking-risk profile to experiment conventional cigarettes. Legislative efforts to ban e-cigarettes with child-friendly flavors should be enhanced.

Motivations and Limitations Associated with Vaping among People with Mental Illness: A Qualitative Analysis of Reddit Discussions

This study aims to understand the nature and significance of online lay discussions about e-cigarettes and mental illness. We systematically searched the website Reddit.com using keywords related to e-cigarettes and mental illness. We coded relevant posts into themes under the framework of motivations for and limitations of vaping for people with mental illness. The thematic analysis included 3263 comments from 133 discussion threads. Six themes were classified as motivations to vape for people with mental illness: Self-medication; Quitting smoking; Freedom and control; Hobby; Social connectedness; and Motivation from caregivers and online communities. The limitations of vaping included: Unsatisfactory substitute for cigarettes and psychiatric medicines; Drug interactions; Nicotine addiction; Risks of e-liquid; Practical difficulties and Cost. People with mental illness; and their carers; use online discussion boards like Reddit to discuss the benefits and limitations of e-cigarettes for people with mental illness. Both positive and negative views exist. Media platforms like Reddit may shape the opinions of stakeholders and generate lay expertise about contentious health topics such as e-cigarettes. These findings have implications for policy and practice concerning assisting smokers with mental illness to reduce their health risk through switching to e-cigarettes.