Quantifying cigarette and e-cigarette marketing exposure among Chinese adolescents using ecological momentary assessment.

INTRODUCTION: Addressing cigarette and e-cigarette use in China is key to reducing the global tobacco epidemic. Marketing exposure is one causal factor for adolescent smoking and e-cigarette use. Currently, China restricts cigarette and e-cigarette ads in public places and online; however, there may not be full policy compliance. We collected real-time data in the natural environment to estimate how much and where Chinese adolescents - a group susceptible to smoking and e-cigarette use - are exposed to cigarette and e-cigarette marketing to inform policy responses. METHODS: In June 2022, we conducted a seven-day ecological momentary assessment (EMA) study with 15-16-year-olds (n=96) across eight Chinese cities. Participants completed up to 42 EMA surveys (6 per day), sent at random intervals outside of school hours. In each survey, participants reported whether they saw (1) displays and (2) ads in the past hour (none, cigarette, e-cigarette, both) in the past hour. We also captured the source of cigarette/e-cigarette ad exposure. RESULTS: Most participants were exposed to cigarette and/or e-cigarette displays (89.6%) or ads (79.2%) over the seven days. On average, participants reported past-hour exposure to displays 12.7 times and past-hour exposure to ads 10.8 times over the week. The most common sources of cigarette ads were public places (e.g., kiosks, supermarkets); the most common sources of e-cigarette ad exposure were social media/internet or e-cigarette stores. CONCLUSIONS: Findings highlight the need to enhance enforcement of restrictions on cigarette and e-cigarette ads in public places and online in China and extend restrictions to ban displays. IMPLICATIONS: Marketing exposure is a causal factor in youth smoking and e-cigarette use. We used ecological momentary assessments to estimate cigarette and e-cigarette display and ad exposure among Chinese adolescents. On average, participants reported past-hour exposure to cigarette and/or e-cigarette displays 13 times and past-hour exposure to cigarette and/or e-cigarette ads 11 times over one week. Most saw ads in public places and online. Results suggest strengthening implementation of China's ban on cigarette and e-cigarette ads in public places and online and banning product displays. These are policy responses that can contribute to reducing adolescent cigarette and e-cigarette uptake in China.

E-cigarette 'tobacco flavor', how do I name thee? Let me count the ways.

INTRODUCTION: In recent years, hundreds of jurisdictions around the world have enacted policies that prohibit sales of flavored e-cigarettes. In most cases, these jurisdictions permit the sale of tobacco flavored e-cigarettes. We sought to understand how tobacco flavor in e-cigarette advertisements were presented. METHODS: Our sample included 2,966 US English language e-cigarette ads compiled by a market research firm, Numerator, that ran from January 2018 to December 2020. We describe the prevalence of different tobacco flavor names in our sample and classified each name into one of the following thematic categories: Traditional Tobacco, Pipe/Cigar Tobacco, Sensory Expectancies, Color, Physical Attribute, Place, and non-characterizing Concept flavor. RESULTS: In our sample, 28% (n=832/2,966) of ads promoted at least one tobacco flavored e-cigarette product (e-cigarette device or liquid). Across the 832 ads, we counted 1,019 tobacco flavored products and identified 51 unique tobacco flavor names. The most common tobacco flavor names were Traditional Tobacco names like 'Tobacco' (n=393), 'Classic tobacco' (n=107) and 'Original' (n=59). Some names were associated with Color (e.g., 'Golden tobacco'; n=153), Sensory Expectancy (e.g., 'Rich tobacco'; n=148), Place where tobacco cultivation takes place (e.g., 'Carolina tobacco'; n=83), Physical Attributes of tobacco (e.g., 'Cut tobacco'; n=17) and non-characterizing Concept flavor (e.g., 'Freedom juice'; n=14). Few tobacco flavors suggested a type of Pipe/Cigar Tobacco (e.g., 'Cavendish'; n=4). CONCLUSION: We identified 51 different tobacco flavor names, highlighting the practice describing the flavor beyond 'tobacco'. Future research can investigate whether these flavor names and descriptors influence consumers' perceptions, including perceived risks, of e-cigarette products. IMPLICATIONS: Flavors are used to market e-cigarettes. Globally, many jurisdictions restrict flavored e-cigarette sales, but few restrict tobacco flavor. This study identified 51 unique ways tobacco flavored e-cigarettes have been named in a sample of US English language ads, suggesting diversified ways to market 'tobacco.' We identified several sub-categories of tobacco flavor names that rely on Color, Sensory Expectancies, and non-characterizing Concept flavor attributes. As e-cigarette flavor restrictions that exempt tobacco flavor are still prevalent, this study highlights the need for continued monitoring of naming conventions of tobacco flavored products and examination of how nuanced flavor names influence perceptions and expectations.

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

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

Exposure to and Appeal of Tobacco Ads and Displays in China: A Qualitative Exploration of Chinese Youth Perceptions.

INTRODUCTION: Adolescents are uniquely vulnerable to nicotine addiction, and smoking is common among male adolescents in China. Although China implemented a ban on cigarette and e-cigarette advertising in public places, Chinese youth remain exposed to this marketing, which may contribute to future use. AIMS AND METHODS: From December 2021 to January 2022, we conducted 20 online focus group discussions with 119 adolescents in 10 Chinese cities to explore sources of tobacco marketing exposure, defined as exposure to cigarette and e-cigarette ads and product displays, and what features made marketing attractive. RESULTS: All groups discussed exposure to tobacco ads/displays in public places, including locations near their home or school. Nearly all groups discussed that exposure to online tobacco ads was common, particularly exposure to e-cigarette commercial ads and posts made by classmates or friends selling e-cigarettes. Most groups identified how eye-catching colors, imagery, product packaging, and price promotions featured in e-cigarette ads/displays attracted their attention. CONCLUSIONS: Results suggest Chinese adolescents are exposed to cigarette and e-cigarette ads and displays, many of which are placed in youth-friendly locations and contain youth-appealing features. IMPLICATIONS: Only a handful of studies have examined the influence of cigarette and e-cigarette advertising on youth in the context of China. Prior research has established the relationship between youth exposure to tobacco marketing and increased susceptibility to future use. Our findings emphasize the importance of effectively enforcing and expanding restrictions on cigarette and e-cigarette marketing in order to protect youth from exposure and future smoking/vaping initiation.

A Cross-Sectional Survey on Oral Nicotine Pouches: Characterizing Use-Motives, Topography, Dependence Levels, and Adverse Events.

INTRODUCTION: Oral nicotine pouches (ONPs) contain a crystalized nicotine powder instead of tobacco leaves. ONPs come in a variety of flavors and are often marketed as "tobacco-free," but research on ONP use-motivations and related experiences is limited. AIMS AND METHODS: This cross-sectional web-based survey collected self-report data on ONP use-characteristics (eg, frequency), brands and flavors used, use-motivations, dependence (Fagerström Test for Nicotine Dependence-Smokeless Tobacco [FTND-ST]), and ONP-related adverse events (AEs) experienced. RESULTS: The sample included 118 adults who reported current (past 30-day) ONP use. On average (SD), participants reported ONP use on 13 (6) days during the past month. Most participants (% of the sample) also reported the use of tobacco cigarettes (74%) and/or electronic cigarettes (53%) during the past month. Zyn (27%) and Lucy (19%) were the most currently used ONP brands with mint (23%) and tobacco (16%) as the most currently used flavors. The availability of preferred flavors was the most frequently reported (31%) ONP use-motivation. The sample demonstrated significant dependence levels (FTND-ST = 7, SD = 2). Reported AEs included mouth lesions (48%), upset stomach (39%), sore mouth (37%), sore throat (21%), and nausea (9%). Results should be interpreted in the context of study limitations, including using a relatively small and homogeneous online convenience sample. Acknowledging the limitations, this sample was deemed appropriate to include considering the novelty of the findings, the dearth of related research, and the necessity of examining foundational ONP use-characteristics (eg, topography, AEs); however, future research should consider recruiting larger and more generalizable samples. CONCLUSIONS: The availability of preferred flavors was a key ONP use-motivation in this sample. Mint and tobacco were the most currently used flavors, with Zyn and Lucy being the most currently used ONP brands. Participants reported dependence and a substantial number of ONP-related AEs. Nationally representative surveys should investigate ONP use along with outcomes included in the current study (eg, AEs) to inform ONP surveillance and policy development efforts. IMPLICATIONS: This study is among the first to assess reasons for initiating/maintaining ONP use as well as other relevant use-experiences (eg, AEs, dependence). These results highlight the role of flavors and nicotine dependence in ONP use, which are important considerations for informing ONP regulations.

Menthol and Other Flavor Chemicals in Cigarettes from Vietnam and the Philippines.

INTRODUCTION: Tobacco product flavors can increase product appeal, adolescent initiation and experimentation, and difficulty quitting. Flavored tobacco products are not restricted in Vietnam or the Philippines despite the high smoking prevalence among those 15 years of age and older (24% and 23%, respectively). There are no published reports to our knowledge on the levels of flavor chemicals in the cigarettes sold in these two countries. METHODS: Cigarettes were purchased in Vietnam (32 brand variants) and the Philippines (19 brand variants) during 2020. Chemical analyses gave the mg/filter, mg/rod, and mg/stick (= mg/(filter + rod)) values for 180 individual flavor chemicals. Values were calculated for menthol, clove-related compounds, and "other flavor chemicals" (OFCs). RESULTS: Five flavor groupings were found among the brand variants purchased in Vietnam: menthol + OFCs (n = 15), OFCs only (n = 8), nonflavored (n = 7), menthol + OFCs with a clove flavorant (n = 1) and menthol only (n = 1). Three flavor groupings were found among the brand variants purchased in the Philippines: menthol + OFCs (n = 10), nonflavored (n = 5), and menthol only (n = 4). CONCLUSIONS: A range of flavored cigarette products are being offered by tobacco companies in Vietnam and the Philippines, presumably to maximize cigarette sales. Regulation of flavor chemicals should be considered in these two countries. IMPLICATIONS: Article 9 of the WHO Framework Convention on Tobacco Control (FCTC), ratified by both Vietnam and the Philippines, states that "there is no justification for permitting the use of ingredients, such as flavoring agents, which help make tobacco products attractive." Flavors increase product appeal, adolescent initiation and experimentation, and difficulty quitting. These analyses found that cigarettes purchased in Vietnam and the Philippines contained menthol and other flavor chemicals. Tobacco companies are offering multiple flavor chemical profiles and nominally nonflavored versions in these countries; regulation of flavor chemicals should be considered in these two countries.

Philip Morris International's Formula 1 Sponsorship-Linked Marketing: Transformation From Marlboro to Mission Winnow.

INTRODUCTION: Transformation describes a dramatic modification in appearance or character. Philip Morris International (PMI)'s sponsorship-linked marketing of Formula 1 auto racing is illustrative of transformation. The company's flagship cigarette brand, Marlboro has been replaced as the identified partner by their newly developed brand, Mission Winnow. This study examines the tobacco company's marketing objectives for transforming the brand identity of its Formula 1 Ferrari race team partnership. AIMS AND METHODS: We provide a case study, and our method of qualitative enquiry is textual analysis. We review marketing planning documents from Philip Morris, which would normally be proprietary, but are publicly accessible because of litigation. Additionally, we review Mission Winnow's social media posts, over a 3-year span, from the brand's Facebook, Instagram, and Twitter accounts. RESULTS: PMI initiated its Formula 1 sponsorship in 1972. Through Marlboro, the company's sponsorship-linked marketing was largely centered on building brand image and reinforcing Marlboro's brand identity of rugged masculinity, independence, heroism, and adventure. When Mission Winnow replaced Marlboro as the identified brand sponsor in 2018, the company's marketing communication shifted to highlighting transformation, progress, open dialogue, teamwork, innovation, technology, and science. CONCLUSIONS: Despite Article 5.3 of the World Health Organization's Framework Convention on Tobacco Control (WHO FCTC) calling for Parties to protect public health policies from the commercial and vested interests of tobacco companies, PMI still seeks to be an important stakeholder in such consultations, including those pertaining to harm reduction. Mission Winnow's sponsorship-linked marketing points to a larger company narrative about trying to gain or reclaim legitimacy and credibility. IMPLICATIONS: PMI's continued sponsorship of Formula 1 is a strategic means of drawing attention to the company's "next-generation products" and communicating their supposed "transformation." The company's sponsorship-linked marketing initiatives point to a need for Parties to enforce Article 13 of the WHO FCTC, which calls for a comprehensive ban on tobacco advertising, promotion, and sponsorship.

Flavored electronic nicotine delivery systems ads (2019-2020) on traditional U.S. Media by audience demographics.

The tobacco industry has historically targeted flavored products to specific U.S. consumer segments, including young people, women, and systemically marginalized groups based on race, ethnicity, or sexual/gender identity. Existing research on target marketing is focused on cigarettes and smokeless tobacco. In contrast, studies of target marketing of electronic nicotine delivery systems (ENDS)-a growing segment of the U.S. tobacco product market - are much more limited. We analyzed data on 496 ENDS ads and audience demographics to explore the extent to which flavored ENDS ads on cable television (n = 25 ads), terrestrial radio (n = 412 ads), and in print consumer magazines (n = 59 ads) are targeted to different demographic groups based on age, sex, and race/ethnicity. We observed flavor-related content in one-quarter to one-third of ENDS ad occurrences during 2019-2020. Across all media outlets examined, audience age was an important factor in explaining the likelihood of ENDS ads containing flavor-related content. For example, within a television channel, there were 3.82 [95% confidence interval (CI): 1.39-10.49] times greater odds that an ENDS ad contained flavor-related content versus not for every 1% increase in the proportion of U.S. youth ages 6-17 watching a television show. In addition, there were 2.13 [95 %CI: 1.30-3.51] and 1.61 [95 %CI:1.60-1.63] times greater odds that an ENDS ad contained flavor-related content versus not in cable television and radio stations, respectively, for every 1% increase in the proportion of male audience members. Race/ethnicity was an important explanatory factor for the presence of flavor-related content on radio but not television ENDS ads. Our findings suggest differences in target marketing of flavored ENDS by media outlet and audience demographics.

Effects of cigarette price and packaging on hypothetical quit-smoking behaviour: a discrete choice experiment among Vietnamese adults who smoke.

INTRODUCTION: Raising cigarette prices, increasing graphic health warning label (HWL) coverage and requiring plain packaging could reduce cigarette smoking in Vietnam. This discrete choice experiment estimates the potential impact of these policies on smoking behaviour. METHODS: In February-May 2022, we conducted a phone-based, cross-sectional survey of 1494 Vietnamese adults who smoke. Participants were randomly assigned to view four individual cigarette pack images, varied on price (15 000 (reference group); 20 000; 30 000 or 40 000 Vietnamese dong (VND)) and packaging (branded pack with 50% graphic HWL (reference group); branded pack with 85% graphic HWL; plain pack with 50% graphic HWL or branded pack without HWL). Participants responded if they would quit or continue smoking if they could only purchase the pack shown. We used binomial logistic regressions to estimate the relative risk (RR) of price and packaging on hypothetical quitting. RESULTS: Participants were more likely to report they would quit when presented with 30 000 VND (RR 1.20, 95% CI 1.07 to 1.35) and 40 000 VND packs (RR 1.40, 95% CI 1.23 to 1.58) vs the 15 000 VND pack. Participants were also more likely to report they would quit when shown the branded pack with 85% HWL (RR 1.30, 95% CI 1.18 to 1.42) and plain pack with 50% HWL (RR 1.34, 95% CI 1.21 to 1.49) vs the branded pack with 50% HWL coverage. Participants had significantly lower quit likelihood (RR 0.41, 95% CI 0.35 to 0.48) when shown the branded pack without a HWL. CONCLUSIONS: Results suggest raising cigarette prices to at least 30 000 VND, implementing larger graphic HWLs or plain packaging could decrease smoking rates in Vietnam.

Presence of flavoured electronic nicotine delivery system (ENDS) products in US ENDS advertisements, 2015-2020: a content analysis.

OBJECTIVES: Electronic nicotine delivery systems (ENDS) products come in a variety of flavours (eg, fruit, dessert, menthol). Tobacco advertising has historically used flavours as an advertising tactic, but little is known about flavour type and prevalence in ENDS advertisements. We assess the presence of flavoured ENDS in ads over time, by media outlet (eg, magazines, online) and brand. METHODS: We acquired ENDS ads (N=4546) that first ran between 2015-2017 (n=1685; study 1) and 2018-2020 (n=2861; study 2) in outlets including opt-in emails, direct-to-consumer mail (study 1 only), video (TV and online), radio (study 2 only), static online/mobile (ie, ads without video or moving graphics), social media, outdoor (eg, billboards; study 2 only) and consumer magazines. We coded for presence of flavoured ENDS products and flavour type (eg, fruit, tobacco, menthol) and merged this information with metadata on ad year, outlet and manufacturer/retailer brand. RESULTS: Overall, nearly half (45.5%; n=2067) of ads in our sample featured a flavoured product. Tobacco (59.1%; n=1221), menthol (42.9%; n=887) and fruit (38.6%; n=797) were the most advertised flavours. Over time, the proportion of ads containing tobacco-flavoured and menthol-flavoured ENDS generally decreased before menthol rebounded in 2020. The proportion of ads containing fruit, mint and dessert flavours generally increased over time, with a substantive drop in 2020. We found notable differences in flavoured ENDS advertising by outlet and brand. CONCLUSIONS: The overall presence of flavoured ENDS in our sample of ads remained relatively consistent, with tobacco flavour decreasing over time and some non-tobacco flavours increasing over time until 2020 when the presence decreased.

Nicotine-related content in English language ENDS advertisements in the US: 2018-2020.

There is no standard way to communicate to consumers how much nicotine is present in electronic nicotine delivery systems (ENDS). This study assessed the inclusion of nicotine-related content, including nicotine strength, in a sample of English language ENDS advertisements that appeared in consumer and business-to-business outlets in the US during 2018-2020. The sample, provided by a media surveillance company, included ads from television, radio, newspapers, magazines (consumer and business-to-business), online platforms, outdoor/billboards, and direct-to-consumer emails. We coded for the presence of nicotine-related content (excluding FDA-required warnings) including nicotine strength presentation, such as mg, mg/ml and percent. The sample included 2966 unique ads, of which 33% (n = 979) featured nicotine-related content. The proportion of ads in the entire sample with nicotine-related content differed by manufacturer/retailer. Ads for Logic e-cigarettes had the highest proportion of nicotine content (62%, n = 258), while ads for JUUL and Vapor4Life had the lowest proportion (13.0% (n = 95) and 19.8% (n = 65), respectively). The proportion of ads with nicotine-related content also differed by media outlet: B2B magazines: 64.8% (n = 68); emails: 41% (n = 529); consumer magazines: 30.4% (n = 41); online: 25.3% (n = 227); television: 20% (n = 6); radio: 19.1% (n = 89); and outdoor (0%, n = 0). Across the sample of ads, 15% reported nicotine strength in mg or mg/ml (n = 444), and 9% reported nicotine strength in percent (n = 260). Most ENDS ads do not include nicotine-related content. There is substantial variation in presentation of nicotine strength, which may present challenges for consumer understanding of absolute and relative nicotine-related content.

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

BACKGROUND: E-cigarette promotion on social media coincided with the rapid growth of e-cigarette use among American youth, particularly with the increased JUUL pod vaporiser use. We examined commercial JUUL-related messages on Instagram to identify marketing appeals used to target users along the continuum of e-cigarette use; we mapped the appeals to existing theoretical marketing frameworks to better understand industry strategies. METHODS: Hashtag-based keyword rules were used to collect JUUL-related posts from the Instagram application programming interface, 1 March-13 November 2018. Posts were classified as commercial or non-commercial. A combination of machine learning methods, keyword algorithms and human coding were used to characterise message themes in commercial posts. RESULTS: Keyword filters captured 50 817 relevant posts and 41% were commercial. Among commercial posts, 91% contained recruitment/trial-based appeals (eg, combustible tobacco cessation; product sampling; giveaways) and 71% featured reinforcement/addiction-related appeals (eg, loyalty programmes). None of the commercial messages contained e-cigarette cessation-related appeals and less than 25% mentioned quitting combustible tobacco as a recruitment appeal. CONCLUSIONS: Instagram posts featuring e-cigarette related marketing can increase exposure to persuasive messages encouraging e-cigarette trial and use particularly among susceptible youth. Stronger regulations are needed to prevent exposure to social media marketing among young social media users.

Standard smokeless tobacco packaging: potential impact on perceived attractiveness, warning label visibility and harm perceptions among adults in Bangladesh.

BACKGROUND: In Bangladesh, smokeless tobacco (SLT) is available in a variety of pack shapes and sizes. Lack of standard packaging could limit compliance with pictorial health warning label (HWL) requirements. We explored Bangladeshi SLT users' and non-users' perceptions of a proposed standard pack shape for gul (tobacco powder) and zordha (chewing tobacco), including the role that HWL placement plays on harm perceptions. METHODS: We conducted 28 focus groups across three regions of Bangladesh: Dhaka, Sylhet and Khulna. Groups were stratified equally by urban/rural residence, gender and SLT use. Trained facilitators used a standardised guide to discuss perceived attractiveness, noticeability of HWLs and perceived harm of current versus standard packs. RESULTS: Most groups found bright colours, 'brand owner' portrait imagery, and strong, sturdy pack material of current packs attractive. Many of the same features increased perceived attractiveness of the standard packs. Pictorial HWLs on the standard packs appeared larger and increased the visibility and noticeability of HWLs compared with current packs. Lack of HWLs or limited visibility of HWL due to discolouration contributed to lower levels of perceived harm of the current packs. In contrast, HWL prominence and placement on both sides of the standard pack increased perceived harm of standard packs. CONCLUSION: The findings suggest a standard shape and size for SLT sold in Bangladesh, coupled with proper implementation of HWLs per the law, could improve HWL noticeability and increase harm perceptions. Additional plain packaging policies that also standardise pack colour may be required to reduce attractive colours and branding.

Culturally specific health-related features on cigarette packs sold in China.

BACKGROUND: China is the country with the highest burden of tobacco-caused disease. We characterised the extent to which cigarette pack marketing features (eg, imagery, text, pack color) could potentially mislead consumers by suggesting products are healthy. METHODS: We used two methods: group concept mapping and content analysis. First, we used a group concept mapping approach to generate and sort Chinese consumer responses to an open-ended prompt asking what marketing features suggest a product is 'healthy' or 'good for you'. Second, based on the concept mapping results, we developed a codebook of health-related features on cigarette packs that were relevant to the unique cultural context of product marketing in China. Two trained coders who were native Chinese speakers double-coded a sample of 1023 cigarette packs purchased in 2013 (wave 1) and 2017 (wave 2). We examined differences in the presence of features overall and over time. RESULTS: Overall, 83.5% (n=854) of Chinese cigarette packs in our sample contained at least one 'healthy' or 'good for you' feature, and the presence of health-related features on packs remained constant between wave 1 (83.5%, n=354) and wave 2 (83.5%, n=500; p=1.00). Across both waves, the most common categories of culturally specific health features present related to recycling symbols, rare animal imagery, bright colours (eg, bright yellow) and botanical imagery (eg, bamboo, mint). CONCLUSION: Health-related features on cigarette packs sold in China are common. Enhanced policies to address tobacco packaging, labelling and branding could support and facilitate a reduction in the high tobacco burden in China.

Identifying credible attribution sources for cigarette health warning labels in China: results from a cross-sectional survey of Chinese adults.

OBJECTIVE: The Framework Convention on Tobacco Control recommends health warning labels (HWLs) include an attribution source. Little is known regarding the perceived credibility and effectiveness of different message sources. This study examined perceptions of four HWL attribution sources among adults in China - the world's largest consumer of cigarettes. DESIGN: Cross-sectional experimental survey design. PARTICIPANTS: Data were collected in 2017 from a convenience sample of 1999 adults across four cities in China; 80% of the sample were current smokers. MAIN OUTCOME MEASURES: Participants viewed four versions of the same HWL, each with a different attribution source: the China Center for Disease Control (ref. group); the regulatory arm of China's domestic tobacco company (STMA); Liyuan Peng, China's first lady; and the WHO. Respondents indicated which HWL was the most: (1) credible, (2) effective at making people quit and (3) effective at preventing youth initiation. RESULTS: Multinomial logistic regression models estimated adjusted relative risk ratios (aRRRs) of the three outcomes. Controlling for demographics and smoking status, HWLs attributed to STMA and Liyuan Peng, respectively, were perceived as significantly less credible (aRRR=0.81, p<0.001; aRRR=0.31, p<0.001), less effective at making people quit (aRRR=0.46, p<0.001; aRRR=0.24, p<0.001) and less effective at preventing young smoking (aRRR=0.52, p<0.001; aRRR=0.39, p<0.001) than the China CDC HWL. There were no significant differences in perceived effectiveness of between the WHO and China CDC HWLs. Participants viewed the WHO HWL as significantly more credible (aRRR=1.21, p<0.001) than the China CDC HWL. CONCLUSION: Results suggest the unique role of health organisations in conveying smoking-related messages that appear credible and effective at motivating others to quit smoking or never start smoking in China. Findings can inform global recommendations regarding HWL attribution sources.

Presence of Nicotine Warning Statement on US Electronic Nicotine Delivery Systems (ENDS) Advertisements 6 Months Before and After the August 10, 2018 Effective Date.

INTRODUCTION: Effective in August 10, 2018, FDA requires advertisements for electronic nicotine delivery systems (ENDS) that meet the definition of a "covered tobacco product" to feature a standard nicotine warning statement. To date, limited data exist on the presence of warning statements in ENDS advertising. METHODS: We acquired ENDS ads (n = 459) that first ran six months before (February 10, 2018-August 9, 2018) and after (August 10, 2018-February 9, 2019) the effective date. The sample included online, print, and outdoor static ads (ie, without video or animated graphics) (n = 166 before, n = 198 after), online and television video ads (n = 16 before, n = 49 after), and radio ads (n = 9 before, n = 21 after). We coded ads for the presence of the verbatim FDA warning. Ads with verbatim warnings were coded for required formatting and additional features. RESULTS: Overall, 28% of static (n = 46/166), 62% of video (n = 10/16), and 67% of radio (n = 6/9) ads that ran before the effective date contained the verbatim warning versus 84% (n = 167/198, p < .001), 96% (n = 47/49, p = .002), and 86% (n = 18/21, p =.329) of ads that ran after, respectively. Following the effective date, nearly all static ads placed the warning as required at the top of the ad (76% [n = 35/46] before, 97% [n = 162/167] after, p < .001), and many video ads featured the warning statement for the entire ad duration (0% [n = 0/10] before, 60% [n = 28/47] after, p < .001). Half (n = 9/18) of radio warnings running after the effective date were read faster than the other promotional content. CONCLUSIONS: The presence of the nicotine warning statement on paid promotional static, video, and radio ENDS ads in this sample increased after August 10, 2018, but a notable number still lacked the warning. IMPLICATIONS: Results from this study provide initial insights into the extent to which required nicotine warning statements appear in ENDS ads in the study sample across traditional (eg, magazines, television, radio) and digital (eg, online/mobile ads) advertising mediums. Following the August 10, 2018, effective date, we observed a substantial increase in the presence of the required FDA warning statement on the ENDS ads in this sample. However, a notable number of ads in the study lacked the required warning and warnings did not always include the required formatting displays.

Evidence of Youth-Appealing Cigarette Advertising Tactics from a Randomized, Controlled Experiment.

INTRODUCTION: Receptivity to tobacco advertising is an important component in the progression from exposure to advertising to use behavior, yet little is known about current tobacco advertising tactics that increase receptivity. This study tests the effect of three advertising features identified in earlier work as potentially appealing to adolescents and young adults: flora imagery, eco-friendly language, and sweepstakes. AIMS AND METHODS: We conducted an online survey in which 1,000 US adolescents (age 15-17) and 1,000 US young adults (age 18-24), equally stratified by smoking status, were exposed to three experimental modules manipulating presence/absence of each feature of interest on cigarette ads. After viewing each ad, participants reported their receptivity to the advertisement. Bivariable analysis and multivariable logistic regression analyses were used to assess the effect of each appeal's presence on receptivity. RESULTS: Adolescents (aOR = 1.55, 95%CI: 1.12-2.14) and young adults (aOR = 1.43, 95%CI: 1.06-1.93) were more likely to be receptive to ads with flora imagery. The effect of sweepstakes on receptivity was modified by the specific ad for young adults. Ecofriendly language did not significantly impact receptivity among either group. Exploratory subgroup analysis found a significant ad by sweepstakes interaction among young adult noncurrent smokers. CONCLUSION: These findings provide evidence that use of flora imagery increases cigarette advertising receptivity among adolescents and young adults, while the effect of sweepstakes on young adults might additionally depend on the ad shown. Restrictions on youth appealing advertising tactics, such as those identified in this study, as well as broader content-neutral advertising restriction policies, should be considered. IMPLICATIONS: This study provides evidence for the appeal of flora imagery in cigarette advertising for both adolescents and young adults, as well as the complexity of how use of sweepstakes interacts with branding in specific ads to predict receptivity among young adults. Because receptivity to cigarette advertising is a documented step in the pathway between advertising exposure and product use, restrictions on use of these tactics should be implemented, and broader content-neutral advertising restriction policies should be considered.