Association Between Social Media Use and Vaping Among Florida Adolescents, 2019

'I'm sure within 5 minutes I can find someone that will be selling it': qualitative insights into how social media facilitates the sale of banned flavoured tobacco products

BACKGROUND

In 2020, Massachusetts became the first state in the USA to restrict the sale of flavoured tobacco products. One demographic group that is disproportionately impacted by flavoured tobacco use is young people. This study explored how Massachusetts' flavour restriction impacted young adults and the ways that flavoured tobacco products were acquired after policy implementation.

METHODS

Between January and March 2024, we conducted 15 virtual, semistructured qualitative interviews with young adults (aged 19-29) who were living in Massachusetts and who reported ever using a flavoured tobacco product. The interview guide included questions about personal tobacco use, awareness of the flavour restriction policy and accessing flavoured tobacco products. After interviews were transcribed and coded, themes were identified.

RESULTS

Only 1 out of 15 participants believed that it would be hard for them to acquire flavoured tobacco products with Massachusetts' policy in place. Social sources were a common way participants reported getting flavoured tobacco products and one-third of participants mentioned seeing them sold on social media platforms. Snapchat was the most frequently reported platform; participants described the 'easy' process of connecting with sellers on Snapchat and how 'openly' people listed the products they had for sale.

CONCLUSIONS

Despite Massachusetts implementing a comprehensive flavoured tobacco restriction (FTR), young adults report being able to access flavoured tobacco products with ease. Snapchat was the social media platform that participants brought up frequently to find people selling flavoured tobacco products. Preventing the sale of flavoured tobacco products through Snapchat and other social sources will be critical for Massachusetts' FTR to have its intended impact.

Worldwide connections of influencers who promote e-cigarettes on Instagram and TikTok: a social network analysis

Exposure to e-cigarette marketing on social media is a risk factor for e-cigarette use among youth. Tobacco brands use influencers to promote e-cigarettes on social media; however, influencer marketing has not been sufficiently studied. This study explored network connections and interactions through comments on social media posts between global nano- and micro-influencers (influencers with approximately 1,000 to 100,000 followers) and their audiences on Instagram and TikTok. We constructed directed unipartite networks among Instagram (N = 104) and TikTok (N = 100) influencers and users on Instagram (N = 55,622) and TikTok (N = 68,673) who commented on these influencers' posts in 2021-2022 (including influencers who commented on each other's posts). Comments to posts of users who were not classified as influencers were not collected. The Instagram network was denser (more interconnected) and active compared to the TikTok network (1.48 times higher density, 281 times higher transitivity, and 85 times higher reciprocity). Both Instagram and TikTok networks contained heterophilic ties (i.e., influencers from different geographic regions such as Asia, North America and Europe connected to each other), indicating that influencers from different geographic regions engage with (comment on) each other's content, potentially exposing audiences to a wide variety of e-cigarette content. Influencers who promote e-cigarettes and post about lifestyle topics (e.g., fitness, fashion, gaming) occupy more central positions in the Instagram and TikTok networks than influencers who focus primarily on e-cigarette promotion, potentially exposing users who are not interested in tobacco-related content to harmful imagery of e-cigarettes. The findings emphasize the need for strengthening influencer marketing regulation on social media platforms popular among youth.

Perspectives, motivations, and experiences of adolescents and young adults using nicotine vapes: a qualitative review

The emergence of vaping represents a novel phenomenon, highlighting its distinctive role within contemporary society. Nevertheless, the comprehensive understanding of the cultural significance and social norms associated with vaping remains incomplete. This scoping review aimed to report the perspectives, motivations, and experiences of adolescents and young adults (10-25 years) engaging in the use of nicotine vapes. Peer-reviewed primary research published in English from 2003 to February 2024 was identified using the databases PubMed, Scopus, CINAHL, and PsycINFO. Qualitative studies reporting on the perspectives, motivations, and experiences of adolescents and young adults who currently engage in nicotine and tobacco vape use were included. Thematic analysis revealed three key themes in adolescents and young adults vaping: understanding and reasons for vaping, the challenges of addiction and withdrawal, and varied responses from families and caregivers. Adolescents and young adults are often introduced to vaping by peers and siblings, drawn by the desire to fit in and the appealing flavours. Despite awareness of potential health risks, addiction makes quitting difficult, leading to intense cravings and withdrawal challenges. Families show a spectrum of responses, from ignorance to reluctant acceptance, indicating a need for better awareness and intervention strategies to address adolescent vaping. Establishing a withdrawal pathway for vaping is imperative as an intervention strategy to address the prevalence of vaping among adolescents and young adults.

Effect of a State-Level Vaping Prevention Campaign on Beliefs and Behaviors in Young People

BACKGROUND

Vaping prevention media campaigns have promising effects on harm perceptions but have yet to demonstrate impacts on vaping behaviors in young people. The goal of this study was to evaluate the effect of Vermont's vaping prevention campaign (Unhyped) on vaping-related beliefs and behaviors.

METHODS

Data come from Waves 5 (Winter 2020) and 9 (Winter 2021) (n = 433) of the Policy and Communication Evaluation Vermont study, a longitudinal online cohort study of adolescents and young adults ages 12-25. Analyses examined associations between awareness of Unhyped in 2020 and outcomes in 2020 and 2021. Primary analyses compared participants aged 12-17 (campaign target) who reported awareness of Unhyped to propensity score-matched controls.

RESULTS

In 2020, more adolescents aware of the Unhyped campaign perceived great risk from weekly vaping compared with matched controls (49.3% vs. 24.3%; p = 0.019). Adolescents aware of Unhyped in 2020 were also less likely than matched controls to report willingness to try a vapor product in the next year (15.8% vs. 40.1%; p = 0.048) or use one if offered by a friend (21.4% vs. 49.1%; p = 0.031) in 2021. There was no relationship between brand awareness and vaping behaviors in 2020 or 2021.

CONCLUSIONS

Although there were no effects of awareness of Vermont's Unhyped campaign on vaping behaviors, the campaign was effective in altering short-term risk perceptions and reducing susceptibility to vape in adolescents one year later.

Effects of E-Cigs on Physiological Pathways and Proposed Therapeutic Intervention with Bixin

Electronic cigarettes (e-cigs) have increased in popularity and usage over the last few decades. There is rising concern regarding the long-term effects of e-cigs on human health, considering their relatively recent introduction to the market. E-cigs are generally composed of a liquid containing nicotine and various chemicals, a battery, a vaporization chamber, and a coil that serves to heat the liquid upon inhalation of the mouthpiece. While e-cigs were initially introduced as a healthy alternative to cigarette smoking, recent research has demonstrated the cytotoxic effects of nicotinic e-cig devices on multiple cell types, including epithelial and endothelial cells, along with causing dysregulation of inflammatory pathways. This review will discuss the harmful effects of e-cigs on the human body, highlighting the physiological impact of e-cigs on pulmonary, cardiovascular, and cerebrovascular health. Moreover, this review will highlight the potential therapeutic effects of bixin, an apocarotenoid found in the seeds of Bixa orellana, also known as the achiote tree, due to its innate anti-inflammatory, antioxidant, and anti-cancer activities that have been demonstrated in recent research. Nanotechnology has surfaced in the past few decades as a powerful tool for medicinal practice. Specifically, nanoparticles serve as a potential method for treating various conditions and diseases. Bixin nanoparticles show promise as a viable method for treating e-cig-induced damage due to the innate properties of bixin and the advantages of using nanoparticles compared to conventional medicinal interventions.

The influence of social media and video-on-demand platforms on the appeal and consumption of tobacco and emerging tobacco products: A cross-sectional study

INTRODUCTION

Digital platforms serve as an avenue for the tobacco industry to promote both conventional tobacco and emerging products, with a notable focus on capturing the attention of young people through sophisticated marketing campaigns. This research aims to analyze the prevalence of different advertising strategies on digital platforms and to assess the impact of exposure to these strategies on the probability of use initiation and increased consumption of conventional tobacco and new tobacco products among young Spaniards.

METHODS

An online survey was conducted on a representative sample of 1730 young Spaniards aged 16-21 years in November 2022 using a comprehensive approach, considering all possible relevant factors and perspectives regarding the issue of the study. A descriptive analysis and two adjusted logistic regression models were employed to explore the association of exposure to digital platforms with the likelihood of conventional tobacco and new tobacco product use among this population.

RESULTS

Among the participants, 83.2% reported witnessing individuals smoking, 61.6% observed identifiable logos or explicit advertisements, and 77.6% encountered indirect product placement on social media. Notably, exposure to conventional tobacco product placement (AOR=1.71; 95% CI: 1.27-2.30) emerged as the variable most significantly associated with an increased probability of tobacco use. Furthermore, exposure to advertising related to new tobacco products (AOR=2.47; 95% CI: 1.90-3.21) was linked to a heightened likelihood of subsequent use. Similarly, the direct promotion of these novel products is also associated with a higher probability of conventional tobacco use (AOR=1.58; 95% CI: 1.21-2.07).

CONCLUSIONS

A reciprocal impact was identified, with the promotion of vaping being associated with an elevated probability of engaging in conventional tobacco smoking. Urgent attention is warranted for formulating public policies to mitigate the adverse effects of such insidious indirect advertising practices on digital platforms.

Social Media Exposure and Other Correlates of Increased e-Cigarette Use Among Adolescents During Remote Schooling: Cross-Sectional Study

Background

Little is known about the role of exposure to e-cigarette-related digital content, behavioral and mental health factors, and social environment on the change in adolescent e-cigarette use during COVID-19 shelter-in-place orders and remote schooling.

Objective

The aim of the study was to examine changes in adolescent e-cigarette use during shelter-in-place and remote schooling in association with exposure to e-cigarette-related digital content and other correlates: stronger e-cigarette dependence, feeling lonely, inability to socialize, e-cigarette use to cope with shelter-in-place, and the number of family members aware of participants' e-cigarette use.

Methods

A cross-sectional survey conducted between August 2020 and March 2021 included 85 California adolescents (mean age 16.7, SD 1.2 years; 39/85, 46% identified as female and 37/85, 44% as Hispanic) who reported e-cigarette use in the past 30 days. Multivariable penalized logistic regressions determined associations adjusted for age, race and ethnicity, and mother's education. The outcome of increased e-cigarette use was defined as more frequent use of e-cigarettes of the same or stronger nicotine or tetrahydrocannabinol concentration.

Results

Almost all respondents (83/85, 98%) reported using social media more since shelter-in-place, and 74% (63/85) reported seeing e-cigarette digital content. More than half (46/85, 54%) reported increased e-cigarette use during shelter-in-place. Most individuals who increased use were exposed to e-cigarette digital content (38/46, 83%) compared to those who did not increase e-cigarette use (25/39, 64%), but the association was nonsignificant after adjusting for demographics (adjusted odds ratio [AOR] 2.34, 95% CI 0.71-8.46). Respondents who felt lonely (AOR 3.33, 95% CI 1.27-9.42), used e-cigarettes to cope with shelter-in-place (AOR 4.06, 95% CI 1.39-13.41), or had ≥2 family members aware of participants' e-cigarette use (AOR 6.42, 95% CI 1.29-39.49) were more likely to report increased e-cigarette use.

Conclusions

Almost all participants reported using social media more during shelter-in-place, with many respondents reporting increased e-cigarette use, and significant associations with loneliness and use to cope with shelter-in-place. Future interventions should consider leveraging digital platforms for e-cigarette use prevention and cessation and address the mental health consequences of the COVID-19 pandemic.

Prospective longitudinal relations among frequent social media use, nicotine vaping and experiencing internalizing mental health problems

AIMS

To compare four a priori rival mediated pathways of frequent social media use, electronic nicotine delivery systems (ENDS) use and internalizing mental health (MH) problems across five waves of nationally representative data.

DESIGN, SETTING AND PARTICIPANTS

This was a longitudinal study using data drawn from waves 2-5 (October 2014-November 2019) of the Population Assessment of Tobacco and Health Study, a nationally representative cohort study spanning approximately 5 years, conducted in the United States. The analytical sample of participants included those who were aged 12-14 years at wave 2 and who provided data in subsequent waves until wave 4.5 (n = 4627, 69.7% were White and 51.4% were male).

MEASUREMENTS

Frequent social media use (several times a day), ENDS use (past 30-day use) and internalizing MH problems (endorsed symptoms on four items in the past year) were dichotomized for analysis.

FINDINGS

The weighted proportions of the three key variables increased over time. From wave 2 to wave 5, frequent social media use grew from 56.9 to 77.2%; internalizing MH problems from 18.9 to 29.0%; and ENDS use from 1.4 to 11.4%. In weighted logistic regressions using generalized linear mixed models with random effects, there was a significant within-person association between frequent social media use at time t and greater ENDS use at t + 1 [adjusted odds ratio (aOR) = 1.87; 95% confidence interval (CI) = 1.47, 2.37] and worsened internalizing MH problems at t + 1 (aOR = 1.19; 95% CI = 1.04, 1.37). A model-based causal mediation analysis and marginal structural models were fitted to estimate the average causal mediation effect. Among all four examined mediation pathways throughout the three constructs, partial mediation was observed, and all the pathways were significant for both boys and girls. Sex differences did not emerge in the examined prospective mediated pathways.

CONCLUSIONS

Among youth in the United States, frequent social media use appears to mediate the prospective association between experiencing internalizing mental health problems and using electronic nicotine delivery systems.

Social media use, brand engagement, and tobacco product initiation among youth: Evidence from a prospective cohort study

OBJECTIVE

To evaluate whether frequent social media use and liking/following tobacco brand accounts was associated with increased risk of tobacco and polytobacco initiation over approximately 1-year follow-up among youth with no prior tobacco use.

METHODS

Associations between measures of social media engagement (daily social media use and liking/following tobacco brands) and tobacco initiation risk were examined using data from Waves 2 and 3 (2014-2015) of the US Population Assessment for Tobacco and Health study. Separate log-binomial models, accounting for missing data via multiple imputation and using propensity score adjustment to address confounding, estimated the adjusted relative risk (aRR) of any tobacco initiation and poly-use (2 + products) initiation at 1-year follow-up.

RESULTS

Among the 8,672 youth with no prior tobacco use (49.3% female, mean [SD] age 14.1 [1.7]), 63.5% used social media at least daily, and 3.3% reported liking/following ≥ 1 tobacco brands on social media. Those reporting daily or more frequent social media use (compared to less) were at increased risk for tobacco (aRR 1.67; 95% CI 1.38-2.02) and polytobacco initiation (aRR 1.32; 95% CI 0.98-1.78). Although results were imprecise, liking/following ≥ 1 tobacco brands on social media (versus none) was associated with tobacco (aRR 1.34; 95% CI 0.95-1.89) or polytobacco initiation (aRR 1.60; 95% CI 0.99-2.60). In sensitivity analyses, liking/following cigarette or cigarillo brands was associated with polytobacco initiation.

CONCLUSIONS

This study adds to a growing evidence-base describing the exposure of youth to tobacco-related social media content. Such content-often generated by tobacco companies-may contribute to youth tobacco initiation.

Characteristics of Adolescents' and Young Adults' Exposure to and Engagement with Nicotine and Tobacco Product Content on Social Media

To inform policy and messaging, this study examined characteristics of adolescents' and young adults' (AYAs') exposure to and engagement with nicotine and tobacco product (NTP) social media (SM) content. In this cross-sectional survey study, AYAs aged 13-26 (N=1,163) reported current NTP use, SM use frequency, and exposure to and engagement with SM content promoting and opposing NTP use (i.e. frequency, source[s], format[s], platform[s]). Participants who used NTPs (vs. did not use) were more likely to report having seen NTP content (p-values<.001). Prevalent sources were companies/brands (46.6%) and influencers (44.4%); prevalent formats were video (65.4%) and image (50.7%). Exposure to content promoting NTP use was prevalent on several popular platforms (e.g. TikTok, Instagram, Snapchat); exposure to content opposing NTP use was most prevalent on YouTube (75.8%). Among those reporting content engagement (i.e. liking, commenting on, or sharing NTP content; 34.6%), 57.2% engaged with influencer content. Participants reported engaging with content promoting and opposing NTP use on popular platforms (e.g. TikTok, Instagram, YouTube). Participants with (versus without) current NTP use were significantly more likely to use most SM platforms and to report NTP content exposure and engagement (p-values<.05). Results suggest that NTP education messaging and enforcement of platforms' content restrictions are needed.

Scalable Surveillance of E-Cigarette Products on Instagram and TikTok Using Computer Vision

INTRODUCTION

Instagram and TikTok, video-based social media platforms popular among adolescents, contain tobacco-related content despite the platforms' policies prohibiting substance-related posts. Prior research identified themes in e-cigarette-related social media posts using qualitative or text-based machine learning methods. We developed an image-based computer vision model to identify e-cigarette products in social media images and videos.

AIMS AND METHODS

We created a data set of 6999 Instagram images labeled for 8 object classes: mod or pod devices, e-juice containers, packaging boxes, nicotine warning labels, e-juice flavors, e-cigarette brand names, and smoke clouds. We trained a DyHead object detection model using a Swin-Large backbone, evaluated the model's performance on 20 Instagram and TikTok videos, and applied the model to 14 072 e-cigarette-related promotional TikTok videos (2019-2022; 10 276 485 frames).

RESULTS

The model achieved the following mean average precision scores on the image test set: e-juice container: 0.89; pod device: 0.67; mod device: 0.54; packaging box: 0.84; nicotine warning label: 0.86; e-cigarette brand name: 0.71; e-juice flavor name: 0.89; and smoke cloud: 0.46. The prevalence of pod devices in promotional TikTok videos increased by 15% from 2019 to 2022. The prevalence of e-juices increased by 33% from 2021 to 2022. The prevalence of e-juice flavor names and e-cigarette brand names increased by about 100% from 2019 to 2022.

CONCLUSIONS

Deep learning-based object detection technology enables automated analysis of visual posts on social media. Our computer vision model can detect the presence of e-cigarettes products in images and videos, providing valuable surveillance data for tobacco regulatory science (TRS).

IMPLICATIONS

Prior research identified themes in e-cigarette-related social media posts using qualitative or text-based machine learning methods. We developed an image-based computer vision model to identify e-cigarette products in social media images and videos. We trained a DyHead object detection model using a Swin-Large backbone, evaluated the model's performance on 20 Instagram and TikTok videos featuring at least two e-cigarette objects, and applied the model to 14 072 e-cigarette-related promotional TikTok videos (2019-2022; 10 276 485 frames). The deep learning model can be used for automated, scalable surveillance of image- and video-based e-cigarette-related promotional content on social media, providing valuable data for TRS. Social media platforms could use computer vision to identify tobacco-related imagery and remove it promptly, which could reduce adolescents' exposure to tobacco content online.

Advertising Exposure From Online and Offline Sources and Youth Tobacco Use: Findings From the Adolescents, Place, and Behavior Study

INTRODUCTION

Tobacco use among adolescents is an ongoing public health concern. Youth tobacco use has been associated with advertising, from both online sources and retail environments.

AIMS AND METHODS

This study examined associations between exposure to tobacco advertisements from tobacco retail outlets (TROs), internet, and social media sources and ever tobacco use among adolescents. Data were obtained from youth, aged 11-17 years (N = 401) from Richmond, VA. Bayesian index and group index models were fitted to estimate indices of exposure to (1) social media use, (2) tobacco ads on social media, and (3) TRO store visits and their association with ever tobacco use. The most important components of the exposure indices were also determined based on the index component weights from the Bayesian index models.

RESULTS

In Bayesian index models of single exposures, each exposure index was significantly associated with tobacco use. In the best-fitting model, social media tobacco ads (odds ratio [OR] = 2.2; 95% credible interval [CI]: 1.2, 4.5) and TRO store visits (OR = 1.6; 95% CI: 1.1, 2.3) were significantly associated with ever tobacco use, as was older age (OR = 1.4; 95% CI: 1.2, 1.8). Index component weights revealed Snapchat ad frequency as the most important platform in the social media index and convenience stores as the most important type of store in the TRO index.

CONCLUSIONS

Exposure to pro-tobacco advertisements on social media and visits to TROs are associated with adolescent ever tobacco use. Results provide support for policies that would restrict the promotion of tobacco products at TROs and on social media. Tobacco regulations and interventions targeting convenience stores and Snapchat may be warranted to reduce youth tobacco use.

IMPLICATIONS

Current evidence provide support for policies that would restrict the promotion of tobacco products at TROs and on social media. Findings suggest that regulations and interventions that specifically target advertisements in convenience stores and on Snapchat may be currently warranted to reduce youth tobacco use.

Characterizing Anti-Vaping Posts for Effective Communication on Instagram Using Multimodal Deep Learning

INTRODUCTION

Instagram is a popular social networking platform for sharing photos with a large proportion of youth and young adult users. We aim to identify key features in anti-vaping Instagram image posts associated with high social media user engagement by artificial intelligence.

AIMS AND METHODS

We collected 8972 anti-vaping Instagram image posts and hand-coded 2200 Instagram images to identify nine image features such as warning signs and person-shown vaping. We utilized a deep-learning model, the OpenAI: contrastive language-image pre-training with ViT-B/32 as the backbone and a 5-fold cross-validation model evaluation, to extract similar features from the Instagram image and further trained logistic regression models for multilabel classification. Latent Dirichlet Allocation model and Valence Aware Dictionary and sEntiment Reasoner were used to extract the topics and sentiment from the captions. Negative binomial regression models were applied to identify features associated with the likes and comments count of posts.

RESULTS

Several features identified in anti-vaping Instagram image posts were significantly associated with high social media user engagement (likes or comments), such as educational warnings and warning signs. Instagram posts with captions about health risks associated with vaping received significantly more likes or comments than those about help quitting smoking or vaping. Compared to the model based on 2200 hand-coded Instagram image posts, more significant features have been identified from 8972 AI-labeled Instagram image posts.

CONCLUSION

Features identified from anti-vaping Instagram image posts will provide a potentially effective way to communicate with the public about the health effects of e-cigarette use.

IMPLICATIONS

Considering the increasing popularity of social media and the current vaping epidemic, especially among youth and young adults, it becomes necessary to understand e-cigarette-related content on social media. Although pro-vaping messages dominate social media, anti-vaping messages are limited and often have low user engagement. Using advanced deep-learning and statistical models, we identified several features in anti-vaping Instagram image posts significantly associated with high user engagement. Our findings provide a potential approach to effectively communicate with the public about the health risks of vaping to protect public health.

Using Computer Vision to Detect E-cigarette Content in TikTok Videos

INTRODUCTION

Previous research has identified abundant e-cigarette content on social media using primarily text-based approaches. However, frequently used social media platforms among youth, such as TikTok, contain primarily visual content, requiring the ability to detect e-cigarette-related content across large sets of videos and images. This study aims to use a computer vision technique to detect e-cigarette-related objects in TikTok videos.

AIMS AND METHODS

We searched 13 hashtags related to vaping on TikTok (eg, #vape) in November 2022 and obtained 826 still images extracted from a random selection of 254 posts. We annotated images for the presence of vaping devices, hands, and/or vapor clouds. We developed a YOLOv7-based computer vision model to detect these objects using 85% of extracted images (N = 705) for training and 15% (N = 121) for testing.

RESULTS

Our model's recall value was 0.77 for all three classes: vape devices, hands, and vapor. Our model correctly classified vape devices 92.9% of the time, with an average F1 score of 0.81.

CONCLUSIONS

The findings highlight the importance of having accurate and efficient methods to identify e-cigarette content on popular video-based social media platforms like TikTok. Our findings indicate that automated computer vision methods can successfully detect a range of e-cigarette-related content, including devices and vapor clouds, across images from TikTok posts. These approaches can be used to guide research and regulatory efforts.

IMPLICATIONS

Object detection, a computer vision machine learning model, can accurately and efficiently identify e-cigarette content on a primarily visual-based social media platform by identifying the presence of vaping devices and evidence of e-cigarette use (eg, hands and vapor clouds). The methods used in this study can inform computational surveillance systems for detecting e-cigarette content on video- and image-based social media platforms to inform and enforce regulations of e-cigarette content on social media.

Problematic social media use and vaping among Mexican-American college students

Introduction

Social media use and vaping nicotine are highly prevalent in the daily lives of young adults, especially among Mexican-American college students. The excessive and compulsive use of social media platforms, coupled with the urge to stay continuously connected, can lead to problematic social media use. To date, no studies have explored the impact of problematic social media use on the daily patterns of vaping among this vulnerable population.

Methods

In Spring 2023, we employed Ecological Momentary Assessment over a period of 14 days to collect real-time daily data on participants' social media use and vaping behaviors via a mobile phone-based application. Participants were 51 Mexican-American college students aged 18-25 years, 72.5% female, who were current vapers. We used generalized linear regression models to examine differences in vaping behaviors among participants with and without problematic social media use. All regression models adjusted for age, sex, and SES.

Results

Participants with problematic social media use vaped on an average of 5.9 days compared to 5.7 days reported by those without problematic social media use (p < .05). Problematic social media use is associated with more frequent daily vaping [b = 0.03; 95% CI: 0.02-0.05], increased number of days vaping [b = 0.14; 95% CI: 0.07-0.20], and vaping higher nicotine concentrations [b = 0.08; 95% CI: 0.03-0.14].

Conclusion

Results suggest that problematic social media use significantly increases the risk of daily vaping among Mexican-American college students. Findings highlight the need to strengthen digital resilience and social media literacy to help college students navigate and mitigate the risks of social media.

Prevalence and correlates of past 30-day dual-vaping of nicotine and cannabis among adolescents in five New England states

SIGNIFICANCE

Adolescent vaping behavior includes vaping of multiple substances, including both nicotine and cannabis (dual-vaping). This study describes the prevalence and the sociodemographic correlates of past 30-day dual-vaping.

METHODS

We recruited adolescents ages 13-17 from five New England states (Massachusetts, Connecticut, Rhode Island, Vermont, New Hampshire) through the Prodege online survey panel from April 2021 to August 2022. Dual-vaping was defined as vaping both nicotine and cannabis (THC and/or CBD) in the past 30-days. We analyzed the prevalence of sole-nicotine, sole-cannabis, and dual-vaping of nicotine and cannabis and used multinomial logistic regression to examine associations between sociodemographic factors and sole- and dual-vaping of nicotine and cannabis.

RESULTS

The analytic sample included 2013 observations from 1858 participants (mean age 15.1 years, 46.2% female, 74.1% White, 82.2% heterosexual). Among these observations, 5.6% reported past 30-day sole-nicotine vaping, 5.5% reported sole-cannabis vaping, and 7.3% had dual-vaped. Correlates for higher odds of past 30-day dual-vaping included total social media sites used and household tobacco use, in contrast with sole-cannabis vaping, which included older age and self-reported depression (all p's <0.05).

DISCUSSION

Adolescent past 30-day dual-vaping of nicotine and cannabis was more prevalent than past 30-day sole-vaping of either nicotine or cannabis alone. Future studies should continue to collect detailed data on the type of substances, besides nicotine, that adolescents are vaping.

Effects of reduced nicotine content cigarette advertising with warning labels and social media features on product perceptions among young adults

This study sought to understand reactions to very low nicotine (VLN) cigarette advertising compared with conventional cigarette advertising with consideration of warning labels and social media context. The online experimental study recruited young adult cigarette smokers and nonsmokers (N = 1,608). Participants completed a discrete choice task with a 2 × 2 × 3 mixed design: brand, (VLN, Marlboro), context (Ad only, Ad on social media), and warning (Text-only, Well-known risk pictorial, or Lesser-known risk pictorial). Participants made choices about attention, appeal, harm, buying, and quitting intentions. Social media context increased attention and appeal. A well-known risk pictorial warning outperformed a text-only warning. Smokers had increased odds of quit intentions for VLN ads, yet nonsmokers had increased intentions to buy cigarettes on social media with a text-only warning. Results indicate differences in how young adults react to cigarette ads on social media, especially with the warnings they portray.

Understanding e-cigarette content and promotion on YouTube through machine learning

INTRODUCTION

YouTube is a popular social media used by youth and has electronic cigarette (e-cigarette) content. We used machine learning to identify the content of e-cigarette videos, featured e-cigarette products, video uploaders, and marketing and sales of e-cigarette products.

METHODS

We identified e-cigarette content using 18 search terms (eg, e-cig) using fictitious youth viewer profiles and predicted four models using the metadata as the input to supervised machine learning: (1) video themes, (2) featured e-cigarette products, (3) channel type (ie, video uploaders) and (4) discount/sales. We assessed the association between engagement data and the four models.

RESULTS

3830 English videos were included in the supervised machine learning. The most common video theme was 'product review' (48.9%), followed by 'instruction' (eg, 'how to' use/modify e-cigarettes; 17.3%); diverse e-cigarette products were featured; 'vape enthusiasts' most frequently posted e-cigarette videos (54.0%), followed by retailers (20.3%); 43.2% of videos had discount/sales of e-cigarettes; and the most common sales strategy was external links for purchasing (34.1%). 'Vape trick' was the least common theme but had the highest engagement (eg, >2 million views). 'Cannabis' (53.9%) and 'instruction' (49.9%) themes were more likely to have external links for purchasing (p<0.001). The four models achieved an F1 score (a measure of model accuracy) of up to 0.87.

DISCUSSION

Our findings indicate that on YouTube videos accessible to youth, a variety of e-cigarette products are featured through diverse videos themes, with discount/sales. The findings highlight the need to regulate the promotion of e-cigarettes on social media platforms.

Mechanisms of E-Cigarette Vape-Induced Epithelial Cell Damage

E-cigarette use has been reported to affect cell viability, induce DNA damage, and modulate an inflammatory response resulting in negative health consequences. Most studies focus on oral and lung disease associated with e-cigarette use. However, tissue damage can be found in the cardio-vascular system and even the bladder. While the levels of carcinogenic compounds found in e-cigarette aerosols are lower than those in conventional cigarette smoke, the toxicants generated by the heat of the vaping device may include probable human carcinogens. Furthermore, nicotine, although not a carcinogen, can be metabolized to nitrosamines. Nitrosamines are known carcinogens and have been shown to be present in the saliva of e-cig users, demonstrating the health risk of e-cigarette vaping. E-cig vape can induce DNA adducts, promoting oxidative stress and DNA damage and NF-kB-driven inflammation. Together, these processes increase the transcription of pro-inflammatory cytokines. This creates a microenvironment thought to play a key role in tumorigenesis, although it is too early to know the long-term effects of vaping. This review considers different aspects of e-cigarette-induced cellular changes, including the generation of reactive oxygen species, DNA damage, DNA repair, inflammation, and the possible tumorigenic effects.

Social Media Use and Subsequent E-Cigarette Susceptibility, Initiation, and Continued Use Among US Adolescents

INTRODUCTION

Social media has a large amount of e-cigarette content. Little is known about the associations between social media use and a wide range of e-cigarette use behaviors, including susceptibility, initiation, and continued use. We analyzed national data on US adolescents to assess these associations.

METHODS

We used data on adolescents participating in the Population Assessment of Tobacco and Health (PATH) Study Wave 4 (2016-2018) and Wave 5 (2018-2019). We conducted 2 models: 1) a multinomial logistic regression on e-cigarette use susceptibility and use behaviors at Wave 5 by social media use at Wave 4 among adolescents who never used e-cigarettes at Wave 4 and 2) a binomial logistic regression on current e-cigarette use at Wave 5 by social media use at Wave 4 among adolescents who ever used e-cigarettes at Wave 4.

RESULTS

Among adolescents who never used e-cigarettes at Wave 4 (n = 7,872), daily social media use (vs never) was associated with a higher likelihood of being susceptible to e-cigarette use (adjusted odds ratio [aOR] =1.46; 95% CI, 1.20-1.78), past e-cigarette use (aOR = 3.55; 95% CI, 2.49-5.06), and current e-cigarette use (aOR = 3.45; 95% CI, 2.38-5.02) at Wave 5. Among adolescents who ever used e-cigarettes at Wave 4 (n = 794), we found no significant association between social media use at Wave 4 and continued e-cigarette use at Wave 5.

CONCLUSION

Our study found that social media use is associated with subsequent susceptibility to e-cigarette use and initiation but not with continued use of e-cigarettes among US adolescents. These findings suggest that understanding and addressing the association between social media and e-cigarette use is critical.

Characteristics Associated with Young Adults' Intentions to Engage with Anti-Vaping Instagram Posts

The purpose of this study was to identify behavioral and sociodemographic factors associated with intentions to engage with anti-vaping Instagram posts among a young adult population. This study proposes the following research questions: (1) Does e-cigarette use status influence intentions to engage with anti-vaping Instagram posts?, and (2) How are e-cigarette use and social media use associated? We recruited a convenience sample of young adults (N = 459; aged 18-30 years) in July of 2022 into an online experimental study from Prolific. Participants saw five image-based Instagram posts about the health harms of using e-cigarettes. Participants were then asked about their intentions to engage ("Comment on", "Reshare", "DM/Send this to a friend", "Like", and/or "Take a screenshot of") with the posts. We used logistic regression to run adjusted models for each engagement outcome, which included fixed effects for sociodemographics, tobacco use, and social media/internet use. For the sum of the engagement outcome, we used Poisson regression. Total number of social media sites used was associated with intentions to "Like" the posts (p = 0.025) and the overall engagement score (p = 0.019), respectively. Daily internet use was associated with intentions to "Comment on" (p = 0.016) and "Like" (p = 0.019) the posts. Young adults who reported past 30-day e-cigarette use had higher odds of using Twitter (p = 0.013) and TikTok (p < 0.001), and a higher total number of social media sites used (p = 0.046), compared to young adults who reported never use e-cigarettes. The initial evidence from our exploratory research using a convenience sample suggests that social media campaigns about the harms of e-cigarette use may be an effective way to engage younger audiences, a generation that frequents social media. Efforts to disseminate social media campaigns should consider launching on multiple platforms, such as Twitter and TikTok, and consider e-cigarette use status when posting.

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

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

Influence of User Profile Attributes on e-Cigarette-Related Searches on YouTube: Machine Learning Clustering and Classification

Background

The proliferation of e-cigarette content on YouTube is concerning because of its possible effect on youth use behaviors. YouTube has a personalized search and recommendation algorithm that derives attributes from a user's profile, such as age and sex. However, little is known about whether e-cigarette content is shown differently based on user characteristics.

Objective

The aim of this study was to understand the influence of age and sex attributes of user profiles on e-cigarette-related YouTube search results.

Methods

We created 16 fictitious YouTube profiles with ages of 16 and 24 years, sex (female and male), and ethnicity/race to search for 18 e-cigarette-related search terms. We used unsupervised (k-means clustering and classification) and supervised (graph convolutional network) machine learning and network analysis to characterize the variation in the search results of each profile. We further examined whether user attributes may play a role in e-cigarette-related content exposure by using networks and degree centrality.

Results

We analyzed 4201 nonduplicate videos. Our k-means clustering suggested that the videos could be clustered into 3 categories. The graph convolutional network achieved high accuracy (0.72). Videos were classified based on content into 4 categories: product review (49.3%), health information (15.1%), instruction (26.9%), and other (8.5%). Underage users were exposed mostly to instructional videos (37.5%), with some indication that more female 16-year-old profiles were exposed to this content, while young adult age groups (24 years) were exposed mostly to product review videos (39.2%).

Conclusions

Our results indicate that demographic attributes factor into YouTube's algorithmic systems in the context of e-cigarette-related queries on YouTube. Specifically, differences in the age and sex attributes of user profiles do result in variance in both the videos presented in YouTube search results as well as in the types of these videos. We find that underage profiles were exposed to e-cigarette content despite YouTube's age-restriction policy that ostensibly prohibits certain e-cigarette content. Greater enforcement of policies to restrict youth access to e-cigarette content is needed.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Neighborhood Characteristics and the Burden of E-Cigarette, or Vaping, Product Use-Associated Lung Injury: An Ecological Comparison Study

Purpose: E-cigarette, or vaping, product use-associated lung injury (EVALI) is a severe consequence of vaping first described in 2019. Investigating associations between neighborhood-level characteristics and EVALI cases is an important step in identifying at-risk communities to implement future targeted prevention programs. Methods: We retrospectively identified 41 adolescents <19 years hospitalized for treatment for EVALI at Children's Medical Center Dallas from December 2018 to June 2021. Patient ZIP codes were extracted from the electronic medical record and were compared with Dallas area ZIP codes containing no EVALI cases. Socioeconomic status (SES) characteristics were obtained from the 2019 American Community Survey, and they were mapped for ZIP codes using ESRI ArcMap geospatial processing software. A parallel analysis was conducted utilizing data of adolescents hospitalized with appendicitis. Results: Ninety-five percent of our cohort used tetrahydrocannabinol-containing products, and 66% obtained their vaping products from informal sources. EVALI cases were less likely to reside in higher SES ZIP codes as measured by the proportion of the population with at least a high school education (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.92-0.99), access to broadband access (OR: 0.95, 95% CI: 0.91-0.99), and private health insurance (OR: 0.97, 95% CI: 0.95-0.99). Alternatively, they were more likely to reside in lower SES ZIP codes as measured by proportion of the population without any health insurance (OR: 1.07, 95% CI: 1.01-1.12). No neighborhood level low SES characteristics were associated with appendicitis hospitalizations. Conclusions: Although small in magnitude, EVALI cases were associated with lower SES ZIP codes but not with vape shop density.

Trends and consumption patterns in the use of e-cigarettes among adolescents and young adults in Germany (the DEBRA study)

INTRODUCTION

Considering the growing popularity and rapid evolution of e-cigarettes, we examined e-cigarette use and tobacco smoking trends, and e-cigarette consumption patterns (i.e., device type, nicotine level) among adolescents and young adults in Germany.

METHODS

Data from 26 waves of the German Study on Tobacco Use (DEBRA), a repeated cross-sectional nationwide household survey, were used to explore trends in the prevalence of ever e-cigarette use and tobacco smoking in a sample of adolescents (aged 14-17 years, N = 1,396) and young adults (aged 18-24 years, N = 4,685) between June/July 2016 and Aug/Sept 2020. Among current e-cigarette users (N = 208), consumption patterns were examined. Associations with e-cigarette use were analysed using multivariable regression.

RESULTS

Adolescent e-cigarette use increased from 9.2% in 2016 to 16.5% in 2017, decreased in 2018 to 8.3% and then gradually increased to 13.4% by 2020. Adolescent tobacco smoking followed a similar trend. Young adult e-cigarette use rates remained relatively stable at 19.1% on average, while tobacco smoking slowly declined (2016: 44.7%, 2020: 38.5%). More than half of current e-cigarette users used refillable-style e-cigarettes (59.4% adolescents; 68.4% young adults) and also smoked tobacco (62.5% adolescents; 79.4% young adults). About 41.6% of adolescents and 56.0% of young adults vaped with nicotine. Among young adults, men (OR = 1.5; 95%CI: 1.3-1.8) and former (OR = 9.6; 95%CI: 1.1-13.1) and current (OR = 10.7; 95%CI: 8.7-13.2) tobacco smokers were more likely to have vaped.

CONCLUSION

E-cigarette use continues to rise in German adolescents and young adults requiring targeted health interventions and campaigns aimed at preventing and/or reducing use in this population.

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.

Aided recall of The Real Cost e-cigarette prevention advertisements among a nationally representative sample of adolescents

E-cigarette use among youth remains a significant public health concern. In 2018, The Real Cost campaign began disseminating messages about the harms of vaping, primarily using digital media. We sought to determine the prevalence of aided recall of The Real Cost e-cigarette prevention ads and identify potential differences by participant characteristics. Participants were a nationally representative sample of adolescents living in United States (US) households recruited by the National Opinion Research Center (NORC) at the University of Chicago's AmeriSpeak panel in September and October of 2020. A total of 623 adolescents completed the survey. Analyses were weighted to represent the distribution of youth in the US, and effect sizes for individual characteristics were estimated using an adjusted marginalized two-part model. Seventy-one percent of adolescents recalled at least one of the five The Real Cost e-cigarette prevention ads, with individual ad recall ranging from a low of 38.8% (for Magic) to a high of 50.1% (for Narrative). Adjusted estimates of aided recall identified significantly higher recall among Black adolescents and those that used social media at medium or high frequencies (p < 0.05). Results support ongoing efforts by the FDA to reach youth with e-cigarette prevention messages using primarily digital media.

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.

A Comprehensive Review of Vaping Use in Pediatric Patients and Recent Changes in Regulatory Laws

The use of electronic cigarettes (e-cigarettes), also known as vapes, by adolescents and young adults has dramatically increased over the past several years. E-cigarettes continue to be the most used form of tobacco among youth. As a result of this concerning trend, policies at both the state and federal levels have been implemented to limit availability in this population. Additionally, the coronavirus disease 2019 (COVID-19) pandemic has had some positive and negative effects on the youth vaping epidemic with adolescent consumers reporting limited access to retail sites during the stay-at-home executive orders, but easier access with online purchasing because age verification was often not required. Complications resulting from vaping have been reported and include e-cigarette or vaping product use-associated lung injury (EVALI) and thrombotic events. Data suggest that the use of vaping devices can lead to both short- and long-term respiratory morbidity in the pediatric population. This review serves to provide a comprehensive examination of vaping use in pediatric patients and recent changes in regulatory laws to equip pharmacists with the knowledge to be aware of the different devices and products available, ask their pediatric patients regularly about use, and counsel and educate on the potential harmful effects.

Changes in Viewer Engagement and Accessibility of Popular Vaping Videos on TikTok: A 12-Month Prospective Study

AIM

There are concerns regarding what young people are exposed to on TikTok due to trending content promoting e-cigarette use through humour, marketing and lifestyle acceptability. Using baseline data from November 2020, we aimed to examine how much content from a sample of popular vaping videos remained accessible at 9- and 12-month follow-ups. We aimed to monitor changes in viewer engagement (using metadata) before and after the U.S. Congressional Hearing on youth protection measures on social media in October 2021.

METHODS

Hashtag-based keywords were used to collect the most viewed publicly available e-cigarette related videos on TikTok (N = 802) from inception to November 2020 to form a baseline. Researchers conducted a longitudinal descriptive study using this data, with 9- and 12-month follow-ups to measure changes in viewer engagement (using metadata) and content availability.

FINDINGS

Of the 802 videos from the baseline, 562 remained at the 9-month follow-up and 511 remained at the 12-month follow-up. At the 12-month follow-up, the majority of vaping-related hashtags were removed by TikTok after the Congressional Hearing. Between the baseline and 9-month follow up, views increased by 1.4% and likes increased by 4.4%. At 12-month follow-up, views had increased by 1.7% and likes by 4.2% compared to baseline data. Whilst 291 videos were no longer publicly accessible at 12-month follow-up, 39 of these were made inaccessible by the content creators. The most viewed and most liked vaping videos at baseline were still publicly available.

CONCLUSIONS

Whilst the depiction type and thematic distribution of removed videos suggest that TikTok may be removing a small proportion of content that promotes the use of e-cigarettes, metadata of remaining videos indicate an increase in viewer engagement. TikTok's removal of explicit substance-related hashtags from the platform could be a step towards preventing adolescents from being exposed to harmful behaviours and substances online. However, the platform should consider enforcing effective age restrictions on content that promotes substance use in a positive light.

[Smoking in Movies: Implementation Status of the World Health Organization Recommendations on the Protection of Minors]

BACKGROUND

 To reduce the exposure of young people to smoking scenes in films, the World Health Organization has recommended classifying films with smoking scenes as unsuitable for children and adolescents.

AIM

 To examine the question whether this recommendation is being implemented in Germany and the USA by comparing the ratings for films with and without smoking scenes in both countries.

METHOD

 The selection criterion for the films was the box office result in German theaters in 2019. The 50 most successful US productions and the 50 most successful productions from Germany were content analyzed. The questions raised were: (1) how high the proportion of smoke-free films was in these two film samples, and (2) how high the proportion of films with smoking scenes was that were classified as unsuitable for young people. All films with an age rating below 16 years were considered suitable for children and adolescents.

RESULTS

 A total of 52 of the 100 films were smokefree. The rate was 64 % for US productions, compared to 40 % for German productions (p = 0.016). According to the German Self-regulatory Organization for the Cinema (FSK) rating system, 87 % of the films were suitable for young people. Overall, the proportion of smokefree films was higher for films suitable for young people than for films not suitable for young people (56 % vs. 23 %; p = 0.025). Of the 48 films with smoking, the FSK classified 79 % as suitable for minors. With regard to the age ratings for films with smoking scenes, there was no difference between the MPAA and FSK ratings for the top 50 US productions.

CONCLUSIONS

 Neither the USA nor Germany has implemented the recommendation of the World Health Organization to protect young people from smoking scenes in films in a satisfactory manner. In Germany, films with smoking scenes are largely classified as suitable for minors.