Considerations and Future Research Directions for E-Cigarette Warnings-Findings from Expert Interviews.
ABSTRACT: Tobacco warning labels are important sources of risk information but research historically has been cigarette-centric. This qualitative study aimed to inform future direction and research on warnings for e-cigarettes. Between June and August 2016, we conducted interviews with 10 researchers with expertise in tobacco warning label research. Interviewees were registrants of a 2016 National Cancer Institute grantee meeting on tobacco warnings. Several participants agreed that the Food and Drug Administration's new nicotine addiction warning for e-cigarettes could be informative but that it might not resonate with young people. Many agreed that more than one warning would be important as e-cigarette science evolves and that research on additional warning themes (e.g., nicotine exposure, harmful constituents) and execution styles (including use of pictorials) was important. Participants were somewhat mixed about the use of reduced-risk messages within e-cigarette warnings, but agreed that research on how to communicate about cigarette/e-cigarette relative risks was needed. Overall, more research is needed on tobacco warnings for non-cigarette products, including on the message content, placement, execution and potential impact on audiences' product knowledge, risk perceptions and use intentions. This is particularly needed for products such as e-cigarettes which may have harm-reduction potential relative to cigarettes and require unique considerations.
Project description:<h4>Introduction</h4>Warning labels can be effective tools to inform the public about tobacco risks. However, tobacco warning research has been largely cigarette-centric. This formative study explores potential directions for improving the current warnings for cigars.<h4>Aims and methods</h4>Between June and August 2019, we conducted interviews with 10 experts about the current cigar warning statements and requirements, the inclusion of pictorials in cigar warnings, and legal issues. Additionally, experts viewed and discussed concept images to pair with existing warning statements, including realistic photographic images and symbolic images (eg, icons, caution symbols).<h4>Results</h4>Experts agreed that cigar warnings should be strengthened (eg, by increasing their size and use of pictorials) to better leverage their potential impact and maintain warning parity with cigarettes. However, perceived challenges exist given the wide variety of cigar products, product terminology, and use patterns. Experts agreed that photographic pictorials of health effects are likely to be more salient, informative, and effective for behavior change than symbolic ones, but may be vulnerable to legal challenges. Symbolic images used in warnings may obtain attention in a less "controversial" way, but may be considered less serious and "factually accurate," increasing legal risks. Experts indicate that cigar educational campaigns can complement warnings and address additional themes, especially aimed at youth, including exposure to chemicals and flavorings and misperceptions that cigars are "natural."<h4>Conclusions</h4>Additional consumer research is needed to examine the potential public health impact of improving cigar warnings and to support regulatory efforts.<h4>Implications</h4>This study provides feedback from tobacco control experts about the importance of cigar warning labels and directions for future research and improvements. Experts support increasing the size of cigar warnings and adopting pictorials to improve cigar warning impact and maintain warning parity with cigarettes. Experts agreed that photographic pictorials of health effects are likely to be more salient and effective for behavior change than symbolic ones. Given legal challenges, experts discussed potentially prioritizing warning improvements for those cigars used most frequently as cigarette alternatives and by youth. Overall, more cigar warning research is needed to support regulatory efforts.
Project description:INTRODUCTION:It is unclear whether warnings on electronic cigarette (e-cigarette) advertisements required by the US Food and Drug Administration (FDA) will apply to social media. Given the key role of social media in marketing e-cigarettes, we seek to inform FDA decision making by exploring how warnings on various tweet content influence perceived healthiness, nicotine harm, likelihood to try e-cigarettes, and warning recall. METHODS:In this 2 × 4 between-subjects experiment participants viewed a tweet from a fictitious e-cigarette brand. Four tweet content versions (e-cigarette product, e-cigarette use, e-cigarette in social context, unrelated content) were crossed with two warning versions (absent, present). Adult e-cigarette users (N = 994) were recruited via social media ads to complete a survey and randomized to view one of eight tweets. Multivariable regressions explored effects of tweet content and warning on perceived healthiness, perceived harm, and likelihood to try e-cigarettes, and tweet content on warning recall. Covariates were tobacco and social media use and demographics. RESULTS:Tweets with warnings elicited more negative health perceptions of the e-cigarette brand than tweets without warnings (p < .05). Tweets featuring e-cigarette products (p < .05) or use (p < .001) elicited higher warning recall than tweets featuring unrelated content. CONCLUSIONS:This is the first study to examine warning effects on perceptions of e-cigarette social media marketing. Warnings led to more negative e-cigarette health perceptions, but no effect on perceived nicotine harm or likelihood to try e-cigarettes. There were differences in warning recall by tweet content. Research should explore how varying warning content (text, size, placement) on tweets from e-cigarette brands influences health risk perceptions. IMPLICATIONS:FDA's 2016 ruling requires warnings on advertisements for nicotine-containing e-cigarettes, but does not specify whether this applies to social media. This study is the first to examine how e-cigarette warnings in tweets influence perceived healthiness and harm of e-cigarettes, which is important because e-cigarette brands are voluntarily including warnings on Twitter and Instagram. Warnings influenced perceived healthiness of the e-cigarette brand, but not perceived nicotine harm or likelihood to try e-cigarettes. We also saw higher recall of warning statements for tweets featuring e-cigarettes. Findings suggest that expanding warning requirements to e-cigarette social media marketing warrants further exploration and FDA consideration.
Project description:Although e-cigarettes in the United States are required to carry one nicotine addiction warning, little is known about the impact of other potential e-cigarette warning themes, nor about pairing warnings with messages that communicate e-cigarettes' reduced-harm potential relative to cigarettes. We randomly assigned 876 young adults (ages 18?29) to view e-cigarette ads in a 3 × 2 plus control online experiment that varied by warning theme (i.e., nicotine addiction; nicotine's impact on adolescent brain development; presence of harmful chemicals) and warning type-i.e., the presence ("relative harm warning") or absence ("standard warning") of a relative harm (RH) statement in the warning label ("e-cigarettes may cause harm to health but are less harmful than cigarettes"). Warning believability, informativeness, understandability and support were high across conditions and there were no significant differences by warning theme on e-cigarette harm perceptions or use intentions nor on nicotine (mis)perceptions. Perceived warning effectiveness for discouraging youth initiation was higher for the "brain" and "chemicals" warnings compared to the addiction warning. Warnings with the included RH statement were perceived as less believable and credible and were less frequently correctly recalled. Research should continue to investigate the impact of different e-cigarette warning themes and formats with priority audiences.
Project description:<h4>Introduction</h4>In 2018, the United States Food and Drug Administration (FDA) required that electronic cigarette (e-cigarette) manufacturers, packagers, importers, distributors, and retailers display an addictive or alternate warning statement on e-cigarette visual advertisements. Few studies have investigated the FDA-mandated and other warnings on social media. This study examined the prevalence and content of warning statements in e-cigarette-related YouTube videos.<h4>Methods</h4>In 2019, The Virginia Commonwealth University Center for the Study of Tobacco Products conducted bi-monthly (February-June) YouTube searches by relevance and view count to identify e-cigarette-related videos. Overall, 178 videos met the inclusion criteria. Staff coded each video for the presence of a visual/verbal warning statement, warning statement type (eg, FDA-mandated, addiction/tobacco, safety/toxic exposure, health effects), sponsorship, and tobacco product characteristics. A data extraction tool collected the video URL, title, upload date, and number of views, likes/dislikes, and comments.<h4>Results</h4>Only 5.1% of videos contained FDA-mandated and 21.9% contained non-mandated warnings. All videos with FDA-mandated and 46.2% of non-mandated warnings were represented visually. Only 13.1% of industry-sponsored videos uploaded after the mandate effective date had an FDA-mandated warning statement and videos with FDA-mandated and non-mandated (v. no) warnings had significantly fewer views, likes, dislikes, and comments. Among all non-mandated warnings, 31.3% featured an addiction/tobacco, 18.8% a safety/toxic exposure, and 37.5% a health effects warning.<h4>Conclusions</h4>The prevalence of FDA-mandated warning statements in e-cigarette related YouTube videos was low. FDA enforcement of the warning statement mandate on YouTube could increase the public's understanding of the addictive nature of nicotine in e-cigarettes.<h4>Implications</h4>The FDA has the authority to regulate the advertisement and promotion of e-cigarettes on the Internet. These data can inform future FDA requirements related to the language content and visual representation of addiction/tobacco, safety/exposure, and health effects warning statements that appear in YouTube videos and other visual social media popular among young people. Such data would help consumers make informed decisions about purchasing e-cigarette products, using e-cigarettes, and avoiding unintentional harm related to e-cigarettes. In addition, these data may help social media platforms make decisions on whether they will prohibit advertisements that promote or facilitate the sale of tobacco products.
Project description:BACKGROUND:E-cigarettes are sold in flavors such as "skittles," "strawberrylicious," and "juicy fruit," and no restrictions are in place on marketing e-cigarettes to youth. Sweets/fruits depicted in e-cigarette advertisements may increase their appeal to youth and interfere with health warnings. This study tested a brain biomarker of product preference for sweet/fruit versus tobacco flavor e-cigarettes, and whether advertising for flavors interfered with warning labels. METHODS:Participants (N?=?26) were college-age young adults who had tried an e-cigarette and were susceptible to future e-cigarette use. They viewed advertisements in fMRI for sweet/fruit and tobacco flavor e-cigarettes, menthol and regular cigarettes, and control images of sweets/fruits/mints with no tobacco product. Cue-reactivity was measured in the nucleus accumbens, a brain biomarker of product preference. Advertisements randomly contained warning labels, and recognition of health warnings was tested post-scan. Visual attention was measured using eye-tracking. RESULTS:There was a significant effect of e-cigarette condition (sweet/tobacco/control) on nucleus accumbens activity, that was not found for cigarette condition (menthol/regular/control). Nucleus accumbens activity was greater for sweet/fruit versus tobacco flavor e-cigarette advertisements and did not differ compared with control images of sweets and fruits. Greater nucleus accumbens activity was correlated with poorer memory for health warnings. CONCLUSIONS:These and exploratory eye-tracking findings suggest that advertising for sweet/fruit flavors may increase positive associations with e-cigarettes and/or override negative associations with tobacco, and interfere with health warnings, suggesting that one way to reduce the appeal of e-cigarettes to youth and educate youth about e-cigarette health risks is to regulate advertising for flavors.
Project description:OBJECTIVE:Cigarette graphic warning labels elicit negative emotion, which increases risk perceptions through multiple processes. We examined whether this emotion simultaneously affects motivated cognitions like smoking myth endorsement (e.g. 'exercise can undo the negative effects of smoking') and perceptions of cigarette danger versus other products. DESIGN:736 adult and 469 teen smokers/vulnerable smokers viewed one of three warning label types (text-only, low emotion graphic or high emotion graphic) four times over two weeks. MAIN OUTCOME MEASURES:Emotional reactions to the warnings were reported during the first and fourth exposures. Participants reported how often they considered the warnings, smoking myth endorsement, risk perceptions and perceptions of cigarette danger relative to smokeless tobacco and electronic cigarettes. RESULTS:In structural equation models, emotional reactions influenced risk perceptions and smoking myth endorsement through two processes. Emotion acted as information about risk, directly increasing smoking risk perceptions and decreasing smoking myth endorsement. Emotion also acted as a spotlight, motivating consideration of the warning information. Warning consideration increased risk perceptions, but also increased smoking myth endorsement. Emotional reactions to warnings decreased perceptions of cigarette danger relative to other products. CONCLUSIONS:Emotional reactions to cigarette warnings increase smoking risk perceptions, but also smoking myth endorsement and misperceptions that cigarettes are less dangerous than potentially harm-reducing tobacco products.
Project description:Health warnings for e-cigarettes are a promising and novel tobacco control intervention for reducing e-cigarette use. We developed a new protocol for evaluating e-cigarette warnings by placing them on users' own devices to reflect real-world exposure. Study 1 participants were a national convenience sample of 606 U.S. adult e-cigarette users surveyed online in March 2017. Most Study 1 participants were willing to have their e-cigarette devices (87%) and refills (83%) labeled. Study 2 participants were a convenience sample of 22 adult e-cigarette users recruited in California, United States in April 2017. We applied the U.S. Food and Drug Administration's proposed e-cigarette warning to users' own devices and refills. Most Study 2 participants (81%) reported using e-cigarette devices with our warning labels at least 90% of the time during the study. Nearly all (95%) said they would participate in the study again, and 100% would recommend the study to a friend. Conversations about e-cigarette harms, conversations about quitting e-cigarettes, and intentions to quit using e-cigarettes increased during the study (all p < 0.05). These studies show that our naturalistic labeling protocol was feasible, acceptable to participants, and had high retention over three weeks. Using the protocol can yield important evidence on the impact of e-cigarette warnings to inform tobacco warning policies.
Project description:This on-line experiment examined whether the addition of ingredient- or industry-themed warning statements in television advertisements for e-cigarettes would affect young adults' craving for and risk perceptions of e-cigarettes and combustible cigarettes, as well as intent to purchase e-cigarettes.Advertisements for two leading e-cigarette brands were edited to contain a warning statement about product ingredients or about the tobacco industry. Participants were assigned randomly to one of eight treatments or one of two brand-specific control conditions without any warning statement.Young adults (n=900, aged 18-34?years) in a web panel were recruited from three groups: recent e-cigarette users, current smokers who used combustible cigarettes exclusively and non-users of either product.Craving and risk perceptions (addictiveness, harmful to health in general, harmful to others) were measured separately for e-cigarettes and combustible cigarettes. The Juster scale measured intention to purchase e-cigarettes.Exposure to both types of warnings was associated with lower craving for e-cigarettes among e-cigarette users and smokers who experienced any craving (P<0.01) and lower intention to purchase among all participants (P<0.001). Only exposure to ingredient-themed warnings was associated with lower craving for combustible cigarettes (P<0.05). Participants who saw industry-themed warnings reported greater perceptions of general harm (P<0.001), but also rated e-cigarettes as less addictive than the control conditions (P<0.05).The addition of ingredient- or industry-themed warning statements to e-cigarette television advertising similarly reduces craving and purchase intent for e-cigarettes, but has inconsistent effects on perceived risks.
Project description:This study was a 3 (Brand: Blu, MarkTen, Vuse) by 3 (Warning Size: 20%, 30%, or 50% of advertisement surface) by 2 (Warning Background: White, Red) experimental investigation of the effects of electronic cigarette (e-cigarette) warning label design features. Young adults aged 18-30 years (n = 544) were recruited online, completed demographic and tobacco use history measures, and randomized to view e-cigarette advertisements with warning labels that varied by the experimental conditions. Participants completed a task assessing self-reported visual attention to advertisements with a-priori regions of interest defined around warning labels. Warning message recall and perceived addictiveness of e-cigarettes were assessed post-exposure. Approximately half of participants reported attending to warning labels and reported attention was greater for warnings on red versus white backgrounds. Recall of the warning message content was also greater among those reporting attention to the warning label. Overall, those who viewed warnings on red backgrounds reported lower perceived addictiveness than those who viewed warnings on white backgrounds, and e-cigarette users reported lower perceived addictiveness than non-users. Among e-cigarette users, viewing warnings on white backgrounds produced perceptions more similar to non-users. Greater recall was significantly correlated with greater perceived addictiveness. This study provides some of the first evidence that e-cigarette warning label design features including size and coloring affect self-reported attention and content recall.
Project description:<h4>Background</h4>The European Commission requires tobacco products sold in the European Union to display standardized text health warnings. This article examines the effectiveness of the text health warnings among daily cigarette smokers in four Member States.<h4>Methods</h4>Data were drawn from nationally representative samples of smokers from the International Tobacco Control Policy Evaluation Project surveys in France (2007), Germany (2007), the Netherlands (2008) and the UK (2006). We examined: (i) smokers' ratings of the health warnings on warning salience, thoughts of harm and quitting and forgoing of cigarettes; (ii) impact of the warnings using a Labels Impact Index (LII), with higher scores signifying greater impact; and (iii) differences on the LII by demographic characteristics and smoking behaviour.<h4>Results</h4>Scores on the LII differed significantly across countries. Scores were highest in France, lower in the UK, and lowest in Germany and the Netherlands. Across all countries, scores were significantly higher among low-income smokers, smokers who had made a quit attempt in the past year and smokers who smoked fewer cigarettes per day.<h4>Conclusion</h4>The impact of the health warnings varies greatly across countries. Impact tended to be highest in countries with more comprehensive tobacco control programmes. Because the impact of the warnings was highest among smokers with the lowest socioeconomic status (SES), this research suggests that health warnings could be more effective among smokers from lower SES groups. Differences in warning label impact by SES should be further investigated.