US adolescents' response to nicotine warning labels in influencer e-cigarette marketing social media posts: a survey-based randomised between-subject experiment.

BACKGROUND: E-cigarette promotional posts with misleading nicotine warning labels on social media may lower adolescents' risk perceptions of e-cigarettes. A between-subject experiment assessed effects of influencers' e-cigarette promotional posts with different nicotine warning labels on adolescents' e-cigarette harm perceptions, susceptibility to e-cigarette use and perceptions of influencer credibility. METHODS: In 2022, adolescents (N=1864, Mage=17 (SD=0.6)) were randomised to view six images and videos featuring influencers promoting e-cigarettes in one of five experimental conditions: two conditions with a 'tobacco-free nicotine' warning label (placed on an e-cigarette in the post or at the top of the post), two conditions with the US Food and Drug Administration (FDA) nicotine warning label (on an e-cigarette in the post or at the top of the post (control)) and one no-label condition. Participants rated influencers' credibility (eg, honesty). Harm perceptions of, and susceptibility to use, e-cigarettes were then assessed. RESULTS: Participants who viewed posts with the FDA warning label at the top of the post perceived influencers as more honest, trustworthy and informed than in all the other conditions. E-cigarette never-users who viewed posts with a 'tobacco-free nicotine' warning label pictured on an e-cigarette (compared with the FDA label at the top of a post) were more likely to report susceptibility to e-cigarette use (adjusted OR 1.79, 95% CI 1.17 to 2.73). CONCLUSIONS: Alterations of the required nicotine warning labels can make them less effective in deterring e-cigarette use behaviour. Tobacco control authorities could increase enforcement of the FDA-required nicotine warning labels and harness influencers for antitobacco messaging.

Evaluating trends in recruitment challenges in vape shop research, e-cigarette product characteristics and use among shop customers from 2019 to 2023: A mixed-methods study.

INTRODUCTION: Brick-and-mortar vape shops specialize in the sale of e-cigarettes and remain a primary source for purchasing emerging e-cigarette products. New regulatory policies have been implemented at local-, state- and federal-level; the retail environment at vape shops and product preferences among vape shop customers shifted accordingly. METHODS: From 2019 to 2023, we collected anonymous interview data from vape shop customers (n=572) from 83 vape shops in Southern California. We aggregated the data by month and treated each month as the unit of analysis to document changes in recruitment efforts among the vape shops in relation to major policy implementations over 4 years. We also examined the systematic fluctuations and trends in customers' e-cigarette product preferences and nicotine content in these products. RESULTS: The monthly average shop-level consent rate was 52.9% (SD=8.7), with an overall decreasing trend over time. It was necessary for our data collection team to approach a greater number of vape shops to obtain consent with implementation of various state and federal tobacco regulations and following COVID-19. We observed an increase in the purchase of disposable products and nicotine concentrations in the products, while the average use frequency remained the same. CONCLUSIONS: Our findings demonstrated that user preferences, product characteristics and challenges in research involving vape shops are closely associated to changes in regulations. We documented a dramatic increase in nicotine concentration in products. Future policies restricting the amount of nicotine in tobacco products at the federal level are necessary to protect consumers from further nicotine addiction. This study provides documentation over time of the drastic increases in nicotine concentration among e-cigarette users as a result of the fluctuations in the product market. Regulating nicotine content in tobacco products could safeguard against further unsafe modifications in e-cigarettes and other types of tobacco products.

Content analysis of email marketing communications among online e-cigarette retailers.

INTRODUCTION: Online e-cigarette retailers use email communications to promote products directly to consumers, which may facilitate e-cigarette use. Little is known about the content of these emails. As such, this study collected emails from online e-cigarette retailers in California to conduct a content analysis. METHODS: This study included 13 online e-cigarette retailers in California using Yelp. To be included in the study, e-cigarette retailers needed a live website, physical retail location (i.e., vape shop), and e-cigarettes available for purchase online. The research team entered each website and signed up (if possible) for an email newsletter. Data were collected from the Gmail Application Programming Interface over a 1-year study period (11/01/21-11/01/22). Members of the research team coded emails for the presence of e-cigarettes, other products, flavors, marketing categories, and promotional activities, among other variables. RESULTS: 749 promotional emails (2.1 avg/per day) were received over the 1-year study period. Second-generation e-cigarettes (n=581, 77.6%) were the most observed product in emails followed by disposable e-cigarettes (n=391, 52.2%). The most common flavor profile was fruit/sweet/liquor (n=424, 56.6%). Emails included links to social media pages (n=366, 48.9%). Online coupons were found in 53.1% (n=398) of the emails. Age warnings were displayed in 8.0% (n=60) of the emails. CONCLUSIONS: E-cigarette retailers' emails promoted new products, flavors, and contained promotional discounts. Future research should examine the impact of exposure to such emails on e-cigarette-related attitudes and behaviors. IMPLICATIONS: Findings from this study may help inform prevention programs and interventions focused on increasing tobacco-related digital media literacy (i.e., evaluate tobacco advertising messages on digital media) among gender and ethnic minorities. Future research should examine if exposure to email marketing is causally linked with e-cigarette use among gender and ethnic minorities.

Adult harm perceptions, purchase, and use related to synthetic vs. tobacco-derived nicotine vaping products: A mixed-methods study.

Objective: Synthetic nicotine (SN) e-cigarettes emerged on the market as an alternative to tobacco-derived nicotine (TDN) vaping products. It is critical to understand the harm perceptions, purchase, and use of SN vs. TDN e-cigarettes. Methods: From November 2021 to February 2023, we conducted intercept interviews with 263 adult customers at 37 vape shops in Southern California. Self-reported use and harm perceptions towards SN vs TDN e-cigarettes were examined. A qualitative analysis of researcher-obtained photographs of vaping items just purchased by customer participants was conducted. Results: Past 30-day SN e-cigarette use was reported by 44 (16.7 %) customers. Past 30-day SN e-cigarette users vs. non-users reported vaping on more days in the past month (29.3 vs. 26.1 days, p = 0.02). Overall, 23.8 % of participants perceived SN e-cigarettes as less harmful than TDN ones; never-smoking vapers and dual users perceived SN e-cigarettes as less harmful than salt-based TDN e-cigarettes. Among 44 customers who purchased SN products (verified through qualitative analysis of photographs), only 13 (29.6 %) self-reported using SN products in the past month, while 5 (11.4 %) indicated they were not aware of the existence of SN products. Most SN vaping products (71.4 %) displayed a modified "tobacco-free" warning label. Conclusions: Misperceptions about SN e-cigarettes were documented in this study, including the perception that SN is either less or more harmful than TDN. Further, some customers may be unknowingly purchasing and using SN e-cigarettes. Regulating "tobacco-free nicotine" terminology in SN vaping products marketing is suggested. SN product labeling should not imply that SN is safe/safer than TDN.

Disposable E-Cigarette Use and Subsequent Use Patterns in Adolescents and Young Adults.

BACKGROUND AND OBJECTIVES: Disposable electronic cigarettes (e-cigarettes) are widely used by adolescents and young adults (AYAs). Whether using disposable devices is associated with future e-cigarette use patterns is unknown but important for informing e-cigarette regulation. METHODS: Prospective longitudinal study combining data from adolescent (14-17 years) and young adult (21-24 years) cohorts from Southern California surveyed at baseline and approximately 8-month follow-up during 2021 to 2022. The analyses included AYAs who used e-cigarettes in the past 30 days at baseline and had exposure and outcome data (N = 403; adolescent n = 124, young adult n = 279). RESULTS: In the pooled sample of AYAs who used e-cigarettes at baseline (57.2% cis-gender female, 56.2% Hispanic), 278 (69.0%) reported past 30-day disposable e-cigarette use, and 125 (31.0%) used only nondisposable e-cigarettes. Baseline use of disposable (versus only nondisposable) devices was associated with higher odds of continued e-cigarette use (adjusted odds ratio = 1.92; 95% confidence interval = 1.09-3.42) and a greater number of times used e-cigarettes per day at follow-up (adjusted incidence rate ratio = 1.29; 95% confidence interval = 1.02-1.63). In supplemental analyses, disposable e-cigarette use was associated with greater odds of no changes (versus reductions) in e-cigarette use frequency and puffs per episode from baseline to follow-up but was not associated with increases in use frequency and intensity. No differences in e-cigarette use outcomes were found between those with poly-device (disposable and nondisposable) versus only disposable device use. CONCLUSIONS: Use of disposable e-cigarette devices among AYAs may be associated with higher risks for persistent e-cigarette use patterns, which should be considered in tobacco product regulation designed to protect AYAs.

Gene-environment transactions between peer cigarette use, parental supervision, and Chinese adolescent cigarette smoking initiation.

INTRODUCTION: The initiation and continued use of tobacco products constitute an ongoing source of preventable disease that continues to pose a significant risk to global adolescent health. Scarce research has sought to explore the influences of two well-known environmental risk factors, parental supervision and peer cigarette use, on genetic and environmental contributions to adolescent cigarette use, especially in non-Western populations. METHODS: Following 602 Chinese twin pairs (52% female, N = 1204) from early to middle adolescence at two-time points (Mage = 12 and 15) from 2006 to 2009 and using multivariate biometric modeling, this study examined gene-environment interplay (i.e., gene-environment correlation and interaction) between perceived parental supervision, peer cigarette use, and adolescent cigarette smoking initiation. RESULTS: From early to middle adolescence, genetic influences on cigarette smoking initiation became more pronounced, whereas shared environmental influences that promote similarity between family members diminished. Genetic factors primarily explained the links between parental supervision and cigarette smoking initiation in mid-adolescence. Peer cigarette use displayed stronger associations with and moderating potential in adolescent cigarette smoking initiation than parental supervision. High levels of peer cigarette use amplified genetic risk for cigarette smoking initiation in mid-adolescence. CONCLUSIONS: Chinese adolescent cigarette smoking initiation involves dynamic gene-environment transactions primarily with peer processes over development. Mid-adolescence constitutes a developmental period wherein underlying genetic risk for cigarette smoking initiation is particularly sensitive to peer influences. Targeted interventions aimed at reducing Chinese adolescent cigarette smoking initiation should focus on peer processes during this developmental period.

Young Adults' Exposure to and Engagement With Tobacco-Related Social Media Content and Subsequent Tobacco Use.

INTRODUCTION: Nicotine/tobacco social media content may increase young people's risk for use. This study examined prospective associations between exposure to and engagement with nicotine/tobacco-related social media content and nicotine/tobacco use among young adults. AIMS AND METHODS: Young adults (N = 2080) originally recruited from Southern California high schools for a prospective cohort study reported frequency of viewing and posting nicotine/tobacco content on four social media platforms (Facebook, Instagram, Twitter, and YouTube). Participants also reported frequency of seeing nicotine/tobacco posts from friends, seeing nicotine/tobacco posts from influencers or celebrities, and liking nicotine/tobacco posts. Within subsamples of nicotine/tobacco never users (n = 794), past users (n = 897) and current users (n = 389), analyses examined associations of baseline (May-October 2020) social media content exposure and engagement with follow-up (January-June 2021) tobacco use initiation (among never users), resumption (among past users), and continuation (among current users), adjusting for sociodemographic and socioenvironmental characteristics. RESULTS: Never users who saw nicotine/tobacco posts from friends (Adjusted Odds Ratio [AOR] = 2.91 [95% Confidence Interval [CI]: 1.46, 5.82], p = .002) or from celebrities or influencers (AOR = 2.77 [1.32, 5.84], p = .007) were significantly more likely to initiate nicotine/tobacco use than their peers. Among past users, posting nicotine/tobacco content at baseline was associated with use resumption (AOR = 1.77 [1.12, 2.80], p = .014). Content exposure and engagement were not associated with nicotine/tobacco use continuation among current users (p-values > .05). CONCLUSIONS: Seeing nicotine/tobacco posts from friends, influencers, or celebrities was associated with greater odds of tobacco use initiation, but not resumption or continuation, 6 months later. Young adults with past nicotine/tobacco use who post about nicotine/tobacco may be at elevated risk for resuming use. IMPLICATIONS: Young adults with exposure to nicotine/tobacco social media content were more likely than their peers to initiate nicotine/tobacco use 6 months later. Past nicotine/tobacco users who reported posting about nicotine/tobacco on social media at baseline were more likely than their peers to resume nicotine/tobacco use. Among young adults with current nicotine/tobacco use at baseline, social media activity did not predict odds of nicotine/tobacco use continuation at follow-up. Nicotine/tobacco content on social media should be restricted to reduce young people's chances of nicotine/tobacco use initiation or resumption.

Assessing the public discourse on Twitter: Reactions to the JUUL e-cigarettes ban in the United States.

INTRODUCTION: JUUL is a high-nicotine pod-based vaping device that is popular among adolescents and young adults. On 23 June 2022, the US Food and Drug Administration (FDA) denied authorization to market JUUL, and ordered JUUL Labs to remove products from the US market. The next day, a US federal appeals court temporarily suspended the ban. The mixed public discourse surrounding the FDA ban warrants further investigation. METHODS: This study examined Twitter data to describe public reaction to these announcements. Posts containing terms 'JUUL' and/or '#JUUL' (N=97548 unique tweets) were collected from 23 June to 3 July 2022, from Twitter's Streaming Application Programming Interface (API). After removing retweets, we used an inductive approach to become familiar with the data, generated a codebook, and conducted a content analysis on a random sample of n=4000 tweets. RESULTS: A total of 2755 (68.9%) tweets discussed JUUL in the context of the FDA ban. News (n=1425/2755; 51.7%) about the JUUL ban, government distrust (n=588; 21.3%), and individual rights (n=253; 9.2%) were the most prevalent themes. Less commonly discussed themes included inconsistencies between policies (n=174; 6.3%), mentions of switching to other products (n=162; 5.9%), smoking cessation (n=99; 3.6%), and craving for JUUL (n=94; 3.4%). Sentiment analysis of JUUL ban-related posts (n=2755) demonstrated that 1989 (72.2%) tweets were categorized as neutral, while anti-ban posts (n=566; 20.5%) were more prevalent than pro-ban posts (n=200; 7.3%). CONCLUSIONS: Besides straightforward announcements of the JUUL ban and its suspension, Twitter posts discussed government distrust, individual rights, and policy inconsistencies. While most posts conveyed neutral sentiments, anti-ban posts were almost three times more prevalent than pro-ban posts. Our findings suggest that text-based social media platforms like Twitter may be an effective instrument to understand opinions, attitudes, and beliefs regarding the FDA's JUUL ban.

Sexual and Gender Identity Disparities in Nicotine and Tobacco Use Susceptibility and Prevalence: Disaggregating Emerging Identities Among Adolescents From California, USA.

INTRODUCTION: Prior studies report nicotine/tobacco use disparities for sexual and gender minority (SGM) youth but have insufficiently characterized SGM identity diversity. AIMS AND METHODS: Adolescents (mean age = 15.2) from 11 high schools in Southern California completed surveys in Fall 2021. Ever use of combustible (cigarettes, cigars, hookah) and noncombustible (e-cigarettes, e-hookah, heated tobacco, smokeless/snus, oral nicotine) nicotine/tobacco (among overall sample, n = 3795) and susceptibility to future initiation of cigarettes, e-cigarettes, and flavored non-tobacco oral nicotine (among n = 3331 tobacco-naïve youth) were compared across four gender (male/masculine, female/feminine, transgender male/female, non-binary) and seven sexual (heterosexual, bisexual, pansexual, queer, questioning, gay/lesbian, asexual) identities. RESULTS: Non-binary (vs. cisgender male) youth had greater prevalence of ever combustible (prevalence ratio [PR] = 2.86, 95% confidence intervals (CI): 1.76 to 4.66) and non-combustible (PR = 1.94, 95% CI: 1.31 to 2.86) nicotine/tobacco use, and susceptibility to future nicotine/tobacco initiation (PR range = 2.32-2.68). Transgender (vs. cisgender male) youth had greater susceptibility to nicotine/tobacco use (PR range = 1.73-1.95), but not greater tobacco use prevalence. There was greater prevalence of non-combustible nicotine/tobacco use (PR range = 1.78-1.97) and susceptibility to nicotine/tobacco initiation (PR range = 1.36-2.18) for all sexual minority (vs. heterosexual) identities, except for asexual. Bisexual (PR = 2.03, 95% CI: 1.30 to 3.16) and queer (PR = 2.87, 95% CI: 1.31 to 6.27) youth had higher ever combustible tobacco use than heterosexual youth. Questioning (vs. heterosexual) youth were more susceptible to future tobacco initiation (PR range = 1.36-2.05) but did not differ in ever use. CONCLUSIONS: Disparities in nicotine/tobacco use and susceptibility were present with similar effect sizes across most, but not all, SGM identities. Inclusive measurement of SGM identities in research and surveillance may inform more precise tobacco control efforts to reduce disparities. IMPLICATIONS: Among high school students from Southern California with substantial diversity in sexual and gender identities, there was greater prevalence of tobacco use and susceptibility to future tobacco initiation for most, but not all, sexual and gender minority youth, including those with emerging sexual and gender identities such as non-binary, queer and pansexual. Additionally, findings indicate that tobacco control initiatives targeting youth who are questioning their sexual identities may be particularly important for preventing tobacco use initiation. This study reinforces the importance of measuring diversity within the LGBTQ + community for tobacco use research, and highlights how inclusive measurement can inform more precise tobacco control interventions.

Oral Nicotine Gum Discussions on Twitter: Content Analysis.

BACKGROUND: Oral nicotine gum such as LUCY, which comes in colorful packaging, mimicking traditional chewing gum, is becoming popular. Many brands of gum have not been approved by the FDA for smoking cessation. This study examined public discourse about, including sentiment toward, oral nicotine gum on Twitter. METHODS: We used Twitter's Streaming Application Programming Interface to collect data from January 1, 2021, to December 21, 2021, using "nicotine gum" and/or "#nicotinegum" search terms (N = 19 171 unique tweets were collected). We used an inductive approach to become familiar with the data, generated a codebook, and conducted a content analysis on (n = 2152) tweets. RESULTS: Cessation (n = 716, 33.3%), personal experience (n = 370, 17.2%), and addiction to gum (n = 135, 6.3%) were the most prevalent themes. Cessation tweets primarily discussed cigarette smoking cessation (n = 418, 58.4% of cessation tweets) and successful cessation experiences (n = 155, 21.6%). Other identified themes pertained to using nicotine gum for cognitive enhancement or catching a "buzz" (n = 102, 4.7%), marketing (n = 98, 4.6%), using nicotine gum with other substances (n = 90, 4.2%), and adverse effects (n = 63, 2.9%). Sentiment analysis results revealed that 675 (44.2%) tweets were categorized as neutral, 605 (39.6%) tweets were classified as positive, and 248 tweets (16.2%) were negative. CONCLUSIONS: About one-third of tweets in our corpus mentioned nicotine gum in the context of smoking cessation. Most nicotine gum-related posts conveyed positive and neutral sentiments. Future studies should consider adding novel nicotine gum-specific search terms as well as exploring other social media platforms to gain more insights about these products. IMPLICATIONS: Our findings suggest that Twitter has the potential to track and facilitate conversations between those seeking cigarette cessation advice and those who have successfully quit tobacco by using nicotine gum. Monitoring of promotional content from nicotine gum companies is needed to ensure these products are not appealing to youth and nonusers of tobacco.

Examining Tobacco-Related Social Media Research in Government Policy Documents: Systematic Review.

BACKGROUND: Social media data have been used to describe tobacco industry marketing practices, user experiences with tobacco, and youth-oriented protobacco content. OBJECTIVE: Examine the extent to which tobacco-related social media research is cited in government policy documents. SEARCH METHODS: Peer-reviewed tobacco-related social media studies were searched for on Web of Science, PubMed, and other databases from 2004 to 2022. The DOI number for each identified article was then used to search the Overton database to find policy documents citing such research. A secondary, manual search of national and international governmental agency websites was also conducted. SELECTION CRITERIA: Documents were included in this study if they were tobacco-related, written in English, cited social media research in the document text and reference section, and were published by a governmental office or agency. DATA COLLECTION AND ANALYSIS: The analytic sample consisted of (n = 38) government policy documents, and were coded for content themes, agency type, document type, and subsequent citations. MAIN RESULTS: When this research was utilized, it was often in the context of highlighting tobacco industry marketing practices, bringing attention to an issue (eg, youth e-cigarette use), and/or describing how social media platforms can be used as a data source to understand tobacco-related attitudes and behaviors. Agencies that often cited this research were the WHO, FDA, and CDC. The document types included research reports, policy recommendations, industry guidance, legal complaints, and practice-based recommendations. CONCLUSIONS: Tobacco-related social media research has been utilized by government agencies in the last decade to guide the policy process. IMPLICATIONS: Tobacco-related social media research has been used in government policy documents to detail tobacco industry marketing and bring attention to youth exposure to protobacco content online. Continued surveillance of social media may be necessary to track the changing tobacco landscape.

Examining the Peer-Reviewed Literature on Tobacco-Related Social Media Data: Scoping Review.

INTRODUCTION: Tobacco researchers have used social media data to examine tobacco industry marketing practices (eg, influencers), and to document user experience with tobacco products. This study summarized the literature that analyzed tobacco-related social media data, including domain, social media platform, tobacco product type, and themes of findings, among other variables. AIMS AND METHODS: PubMed, PsycINFO, Web of Science, and Communication Source were searched between 2004 and 2022. Peer-reviewed articles were included if they were written in English, included at least one tobacco-related term, and one social media-related term, and analyzed a social media post. Two coders screened all-titles and abstracts. The final sample consisted of (n = 255) articles. Studies were coded for domain, social media platform, tobacco product type, data source, type of data, coding and analytic method, and presence of validation procedure, among other variables. RESULTS: A total of 10 504 820 581 tobacco-related social media posts were assessed across 255 studies. User experience (54.1%) and promotion (23.1%) were the most researched domains. Researchers used data from Twitter the most (42.7%). Text (43.1%) was the most common type of data analyzed. Thematic analysis (80.8%) was the most common analytic technique. Themes of findings from content analyses often pertained to the health effects of tobacco use (61.0%) and promotion (44.2%). CONCLUSIONS: Researchers have analyzed billions of tobacco-related social media posts to describe user experience with, and promotions related to, tobacco products like e-cigarettes on platforms like Twitter. Future research may examine tobacco-related social media data from newer platforms like TikTok. IMPLICATIONS: Real-time surveillance of tobacco-related content on social media can keep the tobacco control community abreast of tobacco industry promotional strategies, user experience with tobacco products, and perceived health effects of tobacco use. A framework may be developed to establish best-practices for social media data collection and analysis, including strategies to identify posts from bot accounts and validate methodological approaches used in thematic analysis.

Proximity to Cannabis Retailers and Recent Cannabis Use among a Diverse Sample of California Adolescents.

Background: As of May 2023, 23 states and Washington, DC have legalized the sale of cannabis for adults aged 21+, and 38 states, three territories, and D.C. have legalized medical cannabis. Exposure to cannabis retailers could increase adolescent cannabis use. Few studies have examined the impact of residential proximity to cannabis retailers on adolescent cannabis use, and previous findings are inconsistent. Methods: This study examined associations between proximity to cannabis retailers and past 30-day cannabis use. Data were from Project Cal Teens, a statewide survey of California adolescents regarding cannabis-related opinions/behaviors (N = 1406, mean age = 15.5 years, 48% female, 38% Hispanic/Latinx, 33% White, 15% Asian/Pacific Islander, 10% Black/African American, 5% Other/Multiracial). Participants were recruited via schools/social media in 2018-2020. Results: For every additional 5 driving miles to the nearest cannabis retailer, the risk of past 30-day cannabis use was reduced by 3.6% [IRR: 0.964; 95% CI: 0.935-0.994]. For every additional 5 miles from a licensed retailer, the risk of past 30-day cannabis use was reduced by 4.3% [IRR: 0.957; 95% CI: 0.926-0.989]. Interaction analyses revealed that among Hispanic/Latinx students, every 5 miles from a licensed retailer was associated with an 11.9% reduction in the risk of past 30-day cannabis use [IRR: 0.881; 95% CI: 0.820-0.945]. Conclusions: As the number of cannabis retailers in the U.S. increases with the continued legalization of adult cannabis use, research examining the effects of these policies on underage use is crucial. Interventions could include enforcement of zoning laws in/near residential areas to reduce accessibility of adolescents to cannabis retailers.

Effects of a nicotine warning label and vaping cessation resources on young adults' perceptions of pro-vaping instagram influencer posts.

BACKGROUND: Exposure to social media content promoting e-cigarette use ("vaping") is associated with subsequent tobacco use among young adults. Adding features to pro-vaping Instagram influencer posts, such as a nicotine warning label and vaping cessation resources, could help counteract posts' negative influence. METHODS: Young adults (N = 2,179; Mage = 22.6 [SD = 0.4]; 53.0 % cisgender women, 45.1 % Hispanic) completed an online experiment in 2021-2022 through an ongoing prospective cohort study. Participants viewed three simulated pro-vaping Instagram influencer posts in a four-group, between-subjects design. Post features differed by experimental condition: "label-only" (nicotine warning label on post), "link-only" (link to vaping cessation resources under post), "L&L" (label and link), or "control" (neither). Participants rated each influencer's traits (honest, trustworthy, informed, smart, attractive, popular; 0-100 %). After viewing all three posts, participants reported use intentions, susceptibility, positive and negative expectancies, and harm perceptions around the fictitious advertised vaping product. Past-month vapers additionally reported their desire and self-efficacy for quitting. RESULTS: L&L (versus control and link-only) participants viewed influencers as more honest, trustworthy, and informed. L&L (versus control) participants had lower odds of susceptibility to using the advertised product, lower positive expectancies, and greater negative expectancies. The label and link did not significantly affect participants' intentions to use the product, perceived harm of the product, or desire or self-efficacy for quitting vaping. CONCLUSIONS: Providing a nicotine warning label and link to vaping cessation resources on influencers' Instagram posts may have the unintended effect of increasing positive perceptions of the influencer. However, they may reduce susceptibility to product use.

Effects of flavour and modified risk claims on nicotine pouch perceptions and use intentions among young adults who use inhalable nicotine and tobacco products: a randomised controlled trial.

BACKGROUND: Availability of flavours and potential modified risk tobacco product (MRTP) claims may influence young adults' (YAs') perceptions of and intentions to use nicotine pouches ('pouches'). METHODS: YAs aged 21-34 years (N=47, M age=24.5, SD=3.1) with past-month nicotine/tobacco use (10.6% cigarette-only, 51.1% e-cigarette-only, 38.3% dual use) and no intention to quit were randomised to self-administer four Zyn 3 mg nicotine pouches in a 4 (flavour; within-subjects: smooth, mint, menthol, citrus) × 2 (MRTP claim on packaging; between subjects: present or absent) mixed-factorial design. After self-administering each pouch, participants reported appeal, use intentions and perceived harm compared with cigarettes and e-cigarettes. Three mixed-factorial analysis of variances (ANOVAs) examined main and interactive effects of flavour and MRTP claim on appeal, use intentions and comparative harm perceptions. RESULTS: Mint (M=55.9, SD=26.4), menthol (M=49.7, SD=26.8) and citrus (M=46.6, SD=24.8) flavours were significantly more appealing than smooth (M=37.6, SD=25.4; p<0.001). MRTP claim did not significantly affect product appeal (p=0.376). Use intentions were greater for mint (M=2.6, SD=1.3) and menthol (M=2.0, SD=1.1) flavours than smooth (M=1.8, SD=1.0; p=0.002). Flavour did not affect comparative harm perceptions (p values>0.418). MRTP claims increased use intention (p=0.032) and perceptions of pouches as less harmful than cigarettes (p=0.011), but did not affect perceived harm relative to e-cigarettes (p=0.142). Flavour × MRTP claim interactions were not significant. CONCLUSIONS: Flavoured (vs smooth) pouches were more appealing to YAs. MRTP claims reduced perceived harm of pouches compared with cigarettes; however, intentions to switch were low. To protect YAs' health, regulatory restrictions could target flavours and MRTP claims.

Spanish-language tobacco-related posts on Twitter: content analysis.

INTRODUCTION: Twitter data has been used to surveil public sentiment about tobacco products, however, most tobacco-related Twitter research has been conducted with English-language posts. There is a gap in the literature on tobacco-related discussions on Twitter in languages other than English. This study summarized tobacco-related discussions in Spanish on Twitter. METHODS: A set of Spanish terms reflecting electronic cigarettes (e.g., cigarillos electrónicos), cigarettes (e.g., "pitillo"), and cigars (e.g., "cigaro") were identified. A content analysis of tweets (n=1,352) drawn from 2021 was performed to examine themes and sentiment. An initial codebook was developed in English then translated to Spanish and then translated back to English by a bilingual (Spanish and English) member of the research team. Two bilingual members of the research team coded the tweets into themes and sentiment. RESULTS: Themes in the tweets included 1) product promotion (n=168, 12.4%), 2) health warnings (n=161, 11.9%), 3) tobacco use (n=136, 10.1%), 4) health benefits of vaping (n=58, 4.3%), 5) cannabis use (n=50, 3.7%), 6) cessation (n=47, 3.5%), 7) addiction (n=33, 2.4%), 8) policy (n=27, 2.0%), and 9) polysubstance use (n=12, 0.9%). Neutral (n=955, 70.6%) was the most common category of sentiment observed in the data. CONCLUSIONS: Tobacco products are discussed in multiple languages on Twitter and can be summarized by bilingual research teams. Future research should determine if Spanish-speaking individuals are frequently exposed to pro-tobacco content on social media and if such exposure increases susceptibility to use tobacco among never users or sustained use among current users. IMPLICATIONS: Spanish-language pro-tobacco content exists on Twitter, which has implications for Spanish-speaking individuals who may be exposed to this content. Spanish-language pro-tobacco-related posts may help normalize tobacco use among Spanish-speaking populations. As a result, anti-tobacco tweets in Spanish may be necessary to counter areas of the online environment that can be considered pro-tobacco.

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. METHODS: We created a dataset of 6,999 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 largest number of TikTok videos - 9,091 (65%) - contained smoke clouds, followed by mod and pod devices detected in 6,667 (47%) and 5,949 (42%) videos respectively. Prevalence of nicotine warning labels was the lowest, detected in 980 videos (7%). 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. 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 tobacco regulatory science. 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.

E-Cigarette-Related Health Beliefs Expressed on Twitter Within the U.S.

Introduction: This mixed-methods study analyzed English-language U.S.-based Twitter posts related to E-cigarette use from February 2021. Methods: Posts were manually identified as health-related or not and, if health-related, whether they were posted by an E-cigarette user. A random selection of 1,000 health-related tweets from 986 unique E-cigarette users were qualitatively content analyzed for theory of planned behavior constructs as well as nature and tone of each tweet message. Using quantitative semantic network analysis, relationships among the identified topics and sentiment-specific conversation patterns were explored. Results: The most salient health-related conversation topics of E-cigarette users, health beliefs corresponding to each theory of planned behavior construct, and major motivational contexts of E-cigarette use were identified. Seven topics emerged in positive tweets: smoking cessation, social impact generation, controls over addiction, therapeutic effects on physical and mental health, social support, device attachment, and peer influence. Nine topics emerged in negative tweets: side effects on physical health, vaping addiction, lack of E-cigarette regulations, peer pressure, increased risk of COVID-19, side effects on mental health, no help in smoking cessation, social conflict, and polysubstance use. Most assertions for E-cigarette benefits were not substantiated. Jokes in tweets appeared to contribute to the view of vaping as an attractive, enjoyable, safe, and fun activity. Discussions about positive aspects of E-cigarette use were concentrated on a few related topics, whereas tweets discouraging E-cigarette use presented a diverse, less related set of topics. Conclusions: The results provide insights into the drivers of E-cigarette use behaviors. E-cigarette user perspectives gathered from social media may inform research to guide future prevention and cessation interventions.

A statewide study of disparities in local policies and tobacco, vape, and cannabis retail environments.

The current study: (1) assesses sociodemographic disparities in local policies related to tobacco and cannabis retail, and (2) examines the cross-sectional association between policy strength and retailer densities of tobacco, e-cigarette (vape), and cannabis retailers within California cities and county unincorporated areas (N = 539). We combined (a) American Community Survey data (2019 5-year estimates), (b) 2018 tobacco, vape, and cannabis retailer locations from a commercial data provider, (c) 2017 tobacco and vape retail environment policy data from American Lung Association, and (d) 2018 cannabis policy data from California Cannabis Local Laws Database. Conditional autoregressive models examined policy strength associations with sociodemographic composition and retailer density in California jurisdictions. Jurisdictions with larger percentages of Black and foreign-born residents had stronger tobacco and vape policies. For cannabis policy, only income had a small, significant positive association with policy strength. Contrary to hypothesis, tobacco/vape policies were not significantly associated with retailer density, but cannabis policy strength was associated with lower cannabis retailer density (relative rate = 0.58, 95% Uncertainty Interval 0.47-0.70)-this effect was completely driven by storefront bans. Thus, storefront cannabis bans were the only policy studied that was associated with lower cannabis retailer density. Further research is needed to understand policies and disparities in retail environments for tobacco, vape, and cannabis, including data on the prospective association between policy implementation and subsequent retailer density, and the role of enforcement.

Multilevel perspectives on school-based opportunities to improve HPV vaccination among medically underserved adolescents: Beyond school entry mandates.

School-based HPV vaccination programs have improved vaccine uptake among adolescents globally. However, school-based HPV vaccination strategies in the United States (US) have mainly focused on school-entry mandates for vaccination, which have passed in only five states/jurisdictions. Many schools and school-based health centers (SBHCs) already provide health services to medically underserved adolescents and opportunities to improve disparities in HPV vaccine education and uptake are underexplored. This qualitative study of clinic and community members assessed potential opportunities within and outside schools to increase HPV vaccination. Data were generated from a larger mixed-methods study designed to understand experiences with HPV vaccination evidence-based strategies in medically underserved communities. The parent study included interviews and focus groups conducted with clinic (providers, clinic leaders, staff) and community (racial/ethnic minority parents, advocates, payers, policy representatives) members in Los Angeles and New Jersey between December 2020-January 2022. We created a reduced dataset of text related to schools/SBHCs (30 in-depth interviews, 7 focus groups) and conducted a directed content analysis. Participants indicated that schools and SBHCs are ideal venues for reaching medically underserved adolescents experiencing barriers to primary care access. Parents/providers expressed mutual interest in HPV vaccine administration/education in schools, but some advocates/policy participants experienced challenges due to increasing politicization of vaccines. Participants highlighted policies for expanding HPV vaccine education and administration in schools, including minor consent and increasing SBHC funding for HPV vaccines. More research is needed to explore existing infrastructure, partner motivation, and opportunities to improve HPV vaccination among medically underserved adolescents within schools beyond vaccine mandates.