An Experimental Study of Nicotine Warning Statements in E-cigarette Tweets.
ABSTRACT: 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:Despite concerns about their health risks, e‑cigarettes have gained popularity in recent years. Concurrent with the recent increase in e‑cigarette use, social media sites such as Twitter have become a common platform for sharing information about e-cigarettes and to promote marketing of e‑cigarettes. Monitoring the trends in e‑cigarette-related social media activity requires timely assessment of the content of posts and the types of users generating the content. However, little is known about the diversity of the types of users responsible for generating e‑cigarette-related content on Twitter.The aim of this study was to demonstrate a novel methodology for automatically classifying Twitter users who tweet about e‑cigarette-related topics into distinct categories.We collected approximately 11.5 million e‑cigarette-related tweets posted between November 2014 and October 2016 and obtained a random sample of Twitter users who tweeted about e‑cigarettes. Trained human coders examined the handles' profiles and manually categorized each as one of the following user types: individual (n=2168), vaper enthusiast (n=334), informed agency (n=622), marketer (n=752), and spammer (n=1021). Next, the Twitter metadata as well as a sample of tweets for each labeled user were gathered, and features that reflect users' metadata and tweeting behavior were analyzed. Finally, multiple machine learning algorithms were tested to identify a model with the best performance in classifying user types.Using a classification model that included metadata and features associated with tweeting behavior, we were able to predict with relatively high accuracy five different types of Twitter users that tweet about e‑cigarettes (average F1 score=83.3%). Accuracy varied by user type, with F1 scores of individuals, informed agencies, marketers, spammers, and vaper enthusiasts being 91.1%, 84.4%, 81.2%, 79.5%, and 47.1%, respectively. Vaper enthusiasts were the most challenging user type to predict accurately and were commonly misclassified as marketers. The inclusion of additional tweet-derived features that capture tweeting behavior was found to significantly improve the model performance-an overall F1 score gain of 10.6%-beyond metadata features alone.This study provides a method for classifying five different types of users who tweet about e‑cigarettes. Our model achieved high levels of classification performance for most groups, and examining the tweeting behavior was critical in improving the model performance. Results can help identify groups engaged in conversations about e‑cigarettes online to help inform public health surveillance, education, and regulatory efforts.
Project description:Introduction: While most countries require health warnings on cigarette packs, the Scottish and Canadian Governments are considering requiring health warnings on cigarette sticks. Methods: Twenty focus groups were conducted in Glasgow and Edinburgh (Scotland) with smokers (n?=?120) segmented by age (16-17, 18-24, 25-35, 36-50, >50), gender and social grade, to explore perceptions of cigarettes displaying the warning 'Smoking kills' on the cigarette paper and any demographic differences in how smokers responded to these. Results: A warning on each cigarette was thought to prolong the health message, as it would be visible when a cigarette was taken from a pack, lit, left in an ashtray, and with each draw, and make avoidant behavior more difficult. That it would be visible to others was perceived as off-putting for some. It was felt that a warning on each cigarette would create a negative image and be embarrassing. Within several female groups they were viewed as depressing, worrying and frightening, with it suggested that people would not feel good smoking cigarettes displaying a warning. Within every group there was mention of warnings on cigarettes potentially having an impact on themselves, others or both. Some, mostly younger groups, mentioned stubbing cigarettes out early, reducing consumption or quitting. The consensus was that they would be off-putting for young people, nonsmokers and those starting to smoke. Conclusions: Including a warning on each cigarette stick is a viable policy option and one which would, for the first time, extend health messaging to the consumption experience.
Project description:BACKGROUND:Menthol cigarettes are used disproportionately by African American, female, and adolescent smokers. Twitter is also used disproportionately by minority and younger populations, providing a unique window into conversations reflecting social norms, behavioral intentions, and sentiment toward menthol cigarettes. OBJECTIVE:Our purpose was to identify the content and frequency of conversations about menthol cigarettes, including themes, populations, user smoking status, other tobacco or substances, tweet characteristics, and sentiment. We also examined differences in menthol cigarette sentiment by prevalent categories, which allowed us to assess potential perceptions, misperceptions, and social norms about menthol cigarettes on Twitter. This approach can inform communication about these products, particularly to subgroups who are at risk for menthol cigarette use. METHODS:Through a combination of human and machine classification, we identified 94,627 menthol cigarette-relevant tweets from February 1, 2012 to January 31, 2013 (1 year) from over 47 million tobacco-related messages gathered prospectively from the Twitter Firehose of all public tweets and metadata. Then, 4 human coders evaluated a random sample of 7000 tweets for categories, including sentiment toward menthol cigarettes. RESULTS:We found that 47.98% (3194/6657) of tweets expressed positive sentiment, while 40.26% (2680/6657) were negative toward menthol cigarettes. The majority of tweets by likely smokers (2653/4038, 65.70%) expressed positive sentiment, while 91.2% (320/351) of nonsmokers and 71.7% (91/127) of former smokers indicated negative views. Positive views toward menthol cigarettes were predominant in tweets that discussed addiction or craving, marijuana, smoking, taste or sensation, song lyrics, and tobacco industry or marketing or tweets that were commercial in nature. Negative views toward menthol were more common in tweets about smoking cessation, health, African Americans, women, and children and adolescents-largely due to expression of negative stereotypes associated with these groups' use of menthol cigarettes. CONCLUSIONS:Examinations of public opinions toward menthol cigarettes through social media can help to inform the framing of public communication about menthol cigarettes, particularly in light of potential regulation by the European Union, US Food and Drug Administration, other jurisdictions, and localities.
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: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: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: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: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.