E-cigarette brands and social media influencers on Instagram: a social network analysis.

BACKGROUND: Exposure to visual posts featuring e-cigarette products on social media is associated with increased e-cigarette use among US adolescents. Instagram is the largest source of e-cigarette social media marketing, where influencers-for example, bloggers, brand ambassadors-post promotional materials. This study analysed the network of e-cigarette brands and influencers on Instagram, characterising the most central players in e-cigarette social media marketing. METHODS: We tracked influencers with public profiles on Instagram who posted promotional e-cigarette content in 2020, had over 1000 followers and high user engagement rate (ratio of likes and comments to followers) of 1%-25% per post. By conducting a social network analysis, we identified the most central (highly involved in promotional activities) influencers and e-cigarette brands. The number of the influencers' followers aged 13-17 years old and the age verification practices restricting youth access were also assessed. RESULTS: There is a highly interconnected network of engaging e-cigarette influencers (n=55) worldwide who collaborated with over 600 e-cigarette brands in 2020. The Asian and US influencers had five to six times more teenage followers compared with the European influencers. 75% of the influencers did not restrict youth access to their promotional content on Instagram. The brands Voopotech, Innokin, Geekvape, Lost Vape, Smok and Vaporesso collaborated with the largest number of influencers (mean n=20). CONCLUSIONS: It is important to understand associations among influencers and e-cigarette use behaviours, especially youth, to inform effective public health communication and potential policies that could regulate social media marketing sponsored by e-cigarette companies.

Effect of a hypothetical modified risk tobacco product claim on heated tobacco product use intention and perceptions in young adults.

INTRODUCTION: Modified risk tobacco product (MRTP) claims for heated tobacco products (HTPs) that convey reduced exposure compared with conventional cigarettes may promote product initiation and transition among young people. We assessed the effects of a hypothetical MRTP claim for HTPs on young adults' intention and perceptions of using HTPs and whether these effects differed by their current cigarette and e-cigarette use. METHODS: We embedded a randomised between-subjects experiment into a web-based survey administered among a cohort of 2354 Southern California young adults (aged 20-23) in 2020. Participants viewed depictions of HTPs with an MRTP claim (n=1190) or no claim (n=1164). HTP use intention and HTP-related harm and use perceptions relative to cigarettes and e-cigarettes were assessed. RESULTS: Overall, participants who viewed versus did not view the claim did not differ in HTP use intention (28.5% vs 28.7%) but were more likely to perceive HTPs as less harmful than cigarettes (11.4% vs 7.0%; p<0.001). The experimental effect on HTP use intention did not differ among past 30-day cigarette smokers versus non-smokers (interaction adjusted OR (AOR)=0.78, 95% CI 0.36 to 1.76) but differed among past 30-day e-cigarette users versus non-users (interaction AOR=1.67, 95% CI 1.02 to 2.68). DISCUSSION: The hypothetical MRTP claim may lower young adults' HTP harm perceptions compared with cigarettes but may not change HTP use intention overall or differentially for cigarette smokers. The larger effect on HTP use intention among e-cigarette users than non-users raises the question of whether MRTP claims may promote HTP use or HTP and e-cigarette dual use among young e-cigarette users.

Twitter Surveillance at the Intersection of the Triangulum.

INTRODUCTION: A holistic public health surveillance approach can help capture the public's tobacco and marijuana-related attitudes and behaviors. Using publicly available data from Twitter, this is one of the first studies to describe key topics of discussions related to each intersection (e-cigarette, combustible tobacco, and marijuana) of the Triangulum framework. AIMS AND METHODS: Twitter posts (n = 999 447) containing marijuana, e-cigarette, and combustible tobacco terms were collected from January 1, 2018 to December 23, 2019. Posts to Twitter with co-occurring mentions of keywords associated with the Triangulum were defined as an intersection (e-cigarettes and combustible tobacco, combustible tobacco and marijuana, e-cigarettes and marijuana, and marijuana, e-cigarettes and combustible tobacco). Text classifiers and unsupervised machine learning were used to identify predominant topics in posts. RESULTS: Product Features and Cartridges were commonly referenced at the intersection of e-cigarette and marijuana-related conversations. Blunts and Cigars and Drugs and Alcohol were commonly referenced at the intersection of combustible tobacco and marijuana-related discussions. Flavors and Health Risks were discussed at the intersection of e-cigarette and combustible-related conversations, while discussions about Illicit products and Health risks were key topics of discussion when e-cigarettes, combustible tobacco, and marijuana were referenced all together in a single post. CONCLUSION: By examining intersections of marijuana and tobacco products, this study offers inputs for designing comprehensive FDA regulations including regulating product features associated with appeal, improving enforcement to curb sales of illicit products, and informing the FDA's product review and standards procedures for tobacco products that can be used with marijuana. IMPLICATIONS: This study is the first to leverage the Triangulum framework and Twitter data to describe key topics of discussions at the intersection of e-cigarette, combustible tobacco, and marijuana. Real-time health communication interventions can identify Twitter users posting in the context of e-cigarettes, combustible tobacco, and marijuana by automated methods and deliver tailored messages. This study also demonstrates the utility of Twitter data for surveillance of complex and evolving health behaviors.

Tobacco promotion restriction policies on social media.

Tobacco promotion is prolific on social media, with each platform setting their own restrictions on tobacco promotion and sales. We evaluated the policies related to tobacco product promotion and sales on 11 sites that are popular with youth in May 2021: Discord, Facebook, Instagram, Pinterest, Reddit, Snapchat, TikTok, Tumblr, Twitch, Twitter and YouTube. Nine of the 11 sites prohibited paid advertising for tobacco products. However, only three of them clearly prohibited sponsored content (ie, social influencers) that promotes tobacco. Six platforms restricted content that sells tobacco products and three tried to prohibit underage access to content that promotes or sells tobacco products. Although most platform policies prohibited paid tobacco advertising, few addressed more novel strategies, such as sponsored/influencer content and few had age-gating to prevent youth access. There is a pressing need to regulate tobacco promotion on social media platforms.

Lucy-Novel Flavored Nicotine Gum, Lozenges, and Pouches: Are They Misleading Consumers?

Background: The packaging and marketing of nicotine gums, lozenges, and pouches can influence users' perceptions about which products are evidence-based for tobacco cessation and which are designed for nicotine maintenance-which could keep people nicotine dependent. Lucy, a company that produces flavored nicotine gums, lozenges, and pouches, could cause confusion by mimicking the packaging of traditional chewing gum and using similar marketing for its approved smoking cessation products and non-approved products. Methods: This commentary describes Lucy's marketing practices that could prolong nicotine dependence rather than aid cessation. Results: Lucy's marketing as "FDA approved for smoking cessation" (true for the lozenges but not the gum or pouches) and "PMTA [Premarket Tobacco Product Application] accepted" could create a false narrative of regulatory acceptance. Its scientific conference presentations could imply that it is endorsed by the scientific community. Its colorful pack design, emphasizing flavors and minimizing nicotine warnings, may attract youth and non-nicotine-users to initiate nicotine use. Conclusion: Lucy's promotion of its products as safe alternatives to other forms of tobacco, its packaging that recalls innocuous chewing gum, and its use of social media to advertise its products should be explored by researchers and considered by policymakers for potential population-level health effects.

Vape Shop Employees: Do They Act as Smoking Cessation Counselors?

INTRODUCTION: This study examined smoking cessation advice offered by vape shop employees, as well as their perceived awareness of vaping research. AIMS AND METHODS: This cross-sectional study was conducted in 121 vape shops in the Greater Los Angeles area of Southern California in four multiethnic communities (Hispanic/Latino, African American, Korean/Asian, and non-Hispanic White). A 35-minute interview assessed the employee's tobacco product use, perceptions of vaping research, and experience advising customers to quit cigarette smoking. RESULTS: Among 121 vape shop employees surveyed, 106 (88%) reported that they provided smoking cessation advice or counseling to customers. Nearly half (45%) reported having no vaping-related research knowledge, while 30% were aware of provaping studies only. Approximately 85% of employees had quit cigarettes by switching to e-cigarettes instead, whereas 15% were dual users. Only 49% believed that vaping products contribute to nicotine addiction among youth. Those who provided advice on quitting cigarette smoking reported significantly lower knowledge of e-cigarette research than those who did not provide advice (p < .01). CONCLUSIONS: Most vape shop employees provide advice to customers who desire to quit cigarette smoking and initiate electronic cigarette use. However, they report a low level of awareness about e-cigarette research. Future research is warranted to examine the specifics of advice provided by vape shop employees. Training programs for vape shop employees and educational campaigns about evidence-based scientific findings on vaping may be beneficial. IMPLICATIONS: Almost nine out of 10 surveyed vape shop employees offered cigarette smoking cessation advice to their customers, while almost half of the retailers report not being aware of any vaping-related research studies. Providing employees with training on evidence-based cessation advice could help protect customers. Also, training programs for vape shop employees and educational campaigns about the risk of nicotine addiction could potentially increase their motivation to avoid sales to minors and to warn adults about nicotine addiction.

#FlavorsSaveLives: An Analysis of Twitter Posts Opposing Flavored E-cigarette Bans.

BACKGROUND: Starting in 2019 policies restricting the availability of flavored e-cigarette products were proposed or implemented in the United States to curb vaping by youth. People took to Twitter to voice their opposition, referencing the phrase "Flavors Save Lives." This study documented the emerging themes pertaining to "Flavors Saves Lives" over a 12-month period. METHODS: The study period was from May 1, 2019, to May 1, 2020. A stratified sampling procedure supplied 2500 tweets for analysis. Posts were classified by one or more of the following themes: (1) Political Referendum; (2) Institutional Distrust; (3) Individual Rights; (4) Misinformation; (5) THC Vaping is the Real Problem; (6) Smoking Cessation; (7) Adult Use; and (8) Not a Bot. The temporal pattern of tweets over the year was examined. RESULTS: Political Referendum (76.5%) and Institutional Distrust (31.3%) were the most prominent themes, followed by Not a Bot (11.0%), Individual Rights (10.4%), Adult Use (8.0%), Smoking Cessation (6.6%), Misinformation (5.9%), and THC Vaping is the Real Problem (3.5%). Total tweet frequencies increased in September 2019 and peaked in November 2019 before returning to relatively low numbers. Political Referendum and Institutional Distrust were consistently the most prevalent themes over time. CONCLUSION: Twitter posts with the phrase "Flavors Save Lives" commonly discussed voting against political incumbents and mentioned distrust of government representatives. Findings demonstrated the possibility of near real-time Twitter monitoring of public opposition to flavor bans. These data may be valuable for designing tobacco control information campaigns in the future. IMPLICATIONS: (a) Starting in 2019 policies restricting the availability of flavored e-cigarette products were proposed or implemented in the United States to curb vaping by youth. (b) This study content analyzed Twitter posts with the phrase "Flavors Save Lives" from a 12-month period to understand opposition to flavor restrictions. (c) Twitter posts commonly discussed voting against political incumbents and mentioned distrust of government representatives. (d) Findings demonstrated the possibility of near real-time Twitter monitoring of public opposition to flavor bans, and contribute to a more comprehensive assessment of different sub-population's responses to current and proposed tobacco control information policies.

E-cigarette and cigarette purchasing among young adults before and after implementation of California's tobacco 21 policy.

BACKGROUND: Tobacco 21 (T21) laws, which raise the minimum legal age of sale of tobacco products to 21, have been proposed and implemented in states and cities across the USA. However, limited data are available on the effect of T21 laws on youth tobacco purchasing behaviours and access to tobacco products. METHODS: Participants in a population-based prospective cohort in southern California completed questionnaires before (n=1609, age=18-19 y) and after (n=1502, age=19-20 y) T21 was implemented in California (June 2016). We examined the prevalence of past 30-day cigarette and e-cigarette use, and among past 30-day users, purchase location of tobacco products before (pre-) versus after (post-) T21. We also examined whether, post-T21, participants were refused purchase of tobacco products due to their age, and the perceived relative ease of purchasing cigarettes and e-cigarettes (vs pre-T21). RESULTS: Negligible changes in cigarette and e-cigarette use were observed pre-T21 versus post-T21. At both time points, the majority of past 30-day users purchased cigarettes from gas stations and e-cigarettes from vape shops. Post-T21, the proportion of participants who reported purchasing cigarettes at gas stations decreased. Post-T21, most past 30-day cigarette or e-cigarette users were not refused purchase of cigarettes (65.4%) or e-cigarettes (82.0%) in the past 30 days, despite being under 21; half of the participants felt it was harder to purchase cigarettes (54.3%) and e-cigarettes (43.6%) post-T21. CONCLUSION: Post-T21, few participants were refused purchase of any tobacco product, despite the illegality of such sales. Better enforcement of T21 is needed to improve the efficacy of T21 legislation.

Leading Topics in Twitter Discourse on JUUL and Puff Bar Products: Content Analysis.

BACKGROUND: In response to the recent government restrictions, flavored JUUL products, which are rechargeable closed-system electronic cigarettes (e-cigarettes), are no longer available for sale. However, disposable closed-system products such as the flavored Puff Bar e-cigarette continues to be available. If e-cigarette consumers simply switch between products during the current government restrictions limited to 1 type of product over another, then such restrictions would be less effective. A step forward in this line of research is to understand how the public discusses these products by examining discourse referencing both Puff Bar and JUUL in the same conversation. Twitter data provide ample opportunity to capture such early trends that could be used to help public health researchers stay abreast of the rapidly changing e-cigarette marketplace. OBJECTIVE: The goal of this study was to examine public discourse referencing both Puff Bar and JUUL products in the same conversation on Twitter. METHODS: We collected data from Twitter's streaming application programming interface between July 16, 2019, and August 29, 2020, which included both "Puff Bar" and "JUUL" (n=2632). We then used an inductive approach to become familiar with the data and generate a codebook to identify common themes. Saturation was determined to be reached with 10 themes. RESULTS: Posts often mentioned flavors, dual use, design features, youth use, health risks, switching 1 product for the other, price, confusion over the differences between products, longevity of the products, and nicotine concentration. CONCLUSIONS: On examining the public's conversations about Puff Bar and JUUL products on Twitter, having described themes in posts, this study aimed to help the tobacco control community stay informed about 2 popular e-cigarette products with different device features, which can be potentially substituted for one another. Future health communication campaigns may consider targeting the health consequences of using multiple e-cigarette products or dual use to reduce exposure to high levels of nicotine among younger populations.

Retail Marketing of Menthol Cigarettes in Los Angeles, California: a Challenge to Health Equity.

INTRODUCTION: Sales of menthol cigarettes continue to increase, accounting for a third of the US cigarette market. Retail marketing of menthol cigarettes is a contributing factor to tobacco-related health disparities. To inform regulation to address associated disparities, we examined retail marketing strategies for menthol cigarettes and their features and characteristics in relation to neighborhood racial/ethnic composition. METHODS: We used multilevel regression models to examine associations of neighborhood racial/ethnic composition and store type with menthol cigarette sales outcomes, including availability, exterior advertising, price promotions, and price in a sample of tobacco retailers (N = 673) in Los Angeles County neighborhoods with a median or below-median household income. We also recorded the prices of Newport cigarettes (the highest selling menthol cigarette brand in the United States) and blu disposable menthol e-cigarettes. RESULTS: Overall, 94.5% of retailers sold menthol cigarettes, 31.2% displayed menthol cigarette price promotions, and 30.2% displayed at least one menthol cigarette advertisement on their exterior. Adjusting for racial/ethnic zip code cluster and store type, stores located in predominantly African American neighborhoods showed significantly higher odds in the availability of Newport cigarettes than stores in Hispanic neighborhoods (OR = 0.21; 95% CI, 0.09-0.53; P = .001) or non-Hispanic White (OR = 0.12; 95% CI, 0.05-0.31; P < .001) neighborhoods. Stores located in predominantly African American neighborhoods displayed significantly higher odds of having price promotions for menthol cigarettes and storefront advertisements than those in Hispanic neighborhoods (OR = 0.51; 95% CI, 0.30-0.88; P = .02 and OR = 0.25; 95% CI, 0.13-0.48; P < .001, respectively). CONCLUSION: In 2016 and 2017, menthol cigarettes were widely available in Los Angeles County across racial/ethnic neighborhoods. We found a disproportionate number of storefront advertisements and price promotions for menthol cigarettes in stores located in predominantly African American neighborhoods along with the lowest advertised pack price. This evidence supports tobacco control policies that restrict menthol cigarette sales in the retail environment.

Characterising KandyPens-related posts to Instagram: implications for nicotine and cannabis use.

BACKGROUND: This study analysed posts to Instagram related to KandyPens, an open-system pod mod e-cigarette company, marketing its products as aromatherapy devices. The objective was to determine themes, corresponding user profiles and references to types of e-liquid solutions used with KandyPens. METHODS: Data consisted of publicly available posts to Instagram with the hashtag '#kandypens' collected from 8 June to 8 August 2018 (n=1775). Identified themes included: product appearance (eg, highlighting design features including colour of device), user experience (eg, vape tricks), flavours (eg, strawberry) and promotions (eg, $10 off). The type of e-liquid solutions (nicotine, aromatherapy and cannabis) used with KandyPens were also recorded. Instagram profiles were categorised into: vaping enthusiast/advocates, influencers, KandyPens' official Instagram account, vape vendors and average Instagram users. RESULTS: User experience (28.90%) and product appearance (21.80%) were predominant themes followed by promotions (10.08%), and flavours (1.01%). About 32.43 % of posts referenced cannabis-related solutions, 2.98 % of the posts mentioned nicotine-related solutions and 0.11 % of the posts mentioned aromatherapy. Average Instagram users (24.89%) posted the majority of posts followed by vape vendors (20.72%), KandyPens' official account (17.96%), vaping enthusiasts/advocates (10.75%) and influencers (0.45%). CONCLUSION: KandyPens markets its products as aromatherapy devices; however, Instagram posts related to these products rarely mentioned their purported purpose. Future research should consider product design, user experience and the co-use of nicotine and cannabis with KandyPens to assess implications related to product appeal and abuse liability.

Point-of-sale marketing of little cigars and cigarillos on and near California Tribal lands.

INTRODUCTION: American Indians have the highest cigarette smoking prevalence of any racial/ethnic group in the USA. Tobacco marketing at point-of-sale is associated with smoking, possibly due to easy access to cheap tobacco products. The sale of novel tobacco products like little cigars/cigarillos (LCCs) has increased in recent years which may further increase combustible tobacco use among American Indians. METHODS: Between October 2015 and February 2017, trained community health workers collected LCC product and price information by conducting audits of tobacco retailers on Tribal lands (n=53) and retailers within a 1-mile radius of Tribal lands (n=43) in California. Χ2 analyses were performed to examine associations among the availability and advertising of LCCs, including indoor price promotions and store location. RESULTS: Overall, 85.4% of stores sold LCCs, 76.0% sold flavoured LCCs and 51.0% sold LCCs for less than $1. Indoor price promotions were displayed at 45 (46.9%) stores. Stores within a 1-mile radius of Tribal lands sold significantly more LCC (p<0.01) and flavoured LCCs (p=0.01) than stores on Tribal lands. Stores within a 1-mile radius of Tribal lands also displayed significantly more LCCs priced at less than $1 (p<0.01) than stores on Tribal lands. CONCLUSIONS: LCCs are widely available in stores on and near California Tribal lands. Stores located a short distance away from Tribal lands were more likely to sell LCCs, including flavoured versions, more likely to sell LCCs priced below $1, and more likely to advertise little LCC price promotions than stores on Tribal lands. Policy-makers and Tribal leaders should consider regulations that would limit access to LCCs at point of sale to help prevent youth initiation and reduce smoking-related morbidity and mortality among American Indians.

Tobacco Industry Marketing Exposure and Commercial Tobacco Product Use Disparities among American Indians and Alaska Natives.

Background: Non-Hispanic American Indians and Alaska Natives (NH AI/AN) have the highest commercial tobacco use (CTU) among U.S. racial/ethnic groups. Tobacco marketing is a risk factor, however few studies examine it among NH AI/AN. Objective: We identified prevalence of tobacco industry marketing exposure and correlates of CTU among NH AI/AN compared to other racial/ethnic groups. Methods: Data were from wave 1 (2013-2014; N = 32,320) of the Population Assessment of Tobacco and Health Study, analyzing self-reported exposure to tobacco ads from stores, tobacco package displays, direct mail and email marketing. Correlates of CTU were identified and interactions between racial/ethnic groups and tobacco marketing were assessed. Results: NH AI/AN (n = 955) had a higher prevalence of exposure to retail tobacco ads (64.5% vs 59.3%; p < 0.05), mail (20.2% vs.14.3%; p < 0.001) and email (17.0% vs.10.6%; p < 0.001) marketing than NH Whites (n = 19,297). Adjusting for tobacco use and related risk factors, exposure to email marketing remained higher among NH AI/AN than NH Whites. Interactions between racial/ethnic groups and marketing exposures on CTU were nonsignificant. CTU was higher among NH AI/AN than NH Whites and among adults who reported exposure to tobacco ads, mail, and email marketing. Conclusions/importance: There is higher tobacco marketing exposure in stores and via mail for NH AI/AN. Email marketing exposure was higher, even after controlling for tobacco-related risk factors. The tobacco industry may be targeting NH AI/AN through emails, which include coupons and other marketing promotions. Culturally relevant strategies that counter-act tobacco industry direct marketing tactics are needed to reduce disparities in this population.

Tobacco Marketing and Subsequent Use of Cigarettes, E-Cigarettes, and Hookah in Adolescents.

INTRODUCTION: Tobacco marketing has expanded from cigarettes to other tobacco products through many promotional channels. Marketing exposure is associated with use of that tobacco product. However, it is unclear if marketing for one product leads to subsequent use of other tobacco products. METHODS: This prospective cohort study assessed self-reported marketing exposure for six tobacco products across five marketing channels in 11th and 12th grade students in 2014. Approximately 16 months later, a follow-up survey was conducted online (N = 1553) to assess initiation of cigarettes, electronic cigarettes (e-cigarettes), and hookah. RESULTS: Adolescent never-smokers with frequent exposure to cigarette marketing on the Internet and in stores are more than two times as likely to begin smoking as young adults (Internet OR = 2.98 [95% CI = 1.56 to 5.66]; stores OR = 2.83 [95% CI = 1.23 to 6.50]). Never users of e-cigarettes were significantly more likely to initiate use, if exposed to Internet, store, and outdoor e-cigarette marketing. Never users of hookah were more likely to use hookah after seeing it marketed in stores. Youth exposed to marketing of e-cigarettes, hookah, cigars, smokeless tobacco, and pipe tobacco in stores were two to three times more likely to begin smoking cigarettes even though the marketed products were not cigarettes. CONCLUSIONS: Adolescent exposure to marketing of tobacco products is associated with initiation of those products as young adults. Exposure to marketing for non-cigarette tobacco products is associated with subsequent cigarette smoking, even when the promoted products are not cigarettes. Future research and interventions should consider the influence of marketing from multiple tobacco products on adolescent tobacco use. IMPLICATIONS: Adolescents grow up in a rich media environment with exposure to tobacco marketing in both their homes (eg, through the Internet and television) and their communities (eg, stores and billboards). This prospective study provides evidence that adolescents exposed to tobacco marketing for multiple tobacco products are more likely to subsequently begin using those products and to begin smoking cigarettes even when the marketing they recall is for different tobacco products. Adolescent exposure to tobacco marketing can increase likelihood of cigarette smoking, e-cigarette, and hookah use with potential lifelong health effects.

Tobacco Advertisement Liking, Vulnerability Factors, and Tobacco Use Among Young Adults.

INTRODUCTION: Young adulthood (aged 18-24) is a crucial period in the development of long-term tobacco use patterns. Tobacco advertising and promotion lead to the initiation and continuation of smoking among young adults. We examined whether vulnerability factors moderated the association between tobacco advertisement liking and tobacco use in the United States. METHODS: Analyses were conducted among 9109 US young adults in the nationally representative Population Assessment of Tobacco and Health (PATH) Study wave 1 (2013-14). Participants viewed 20 randomly selected sets of tobacco advertisements (five each for cigarettes, e-cigarettes, cigars, and smokeless tobacco) and indicated whether they liked each ad. The outcome variables were past 30-day cigarette, e-cigarette, cigar, and smokeless tobacco use. Covariates included tobacco advertisement liking, age, sex, race or ethnicity, sexual orientation, education, poverty level, military service, and internalizing and externalizing mental health symptoms. RESULTS: Liking tobacco advertisements was associated with tobacco use, and this association was particularly strong among those with lower educational attainment (cigarettes, cigars) and living below the poverty level (e-cigarettes, smokeless tobacco). CONCLUSIONS: The association between tobacco advertisement liking and tobacco use was stronger among young adults with lower educational attainment and those living below the poverty level. Policies that restrict advertising exposure and promote counter-marketing messages in this population could reduce their risk. IMPLICATIONS: This study shows that liking tobacco advertisements is associated with current tobacco use among young adults, with stronger associations for vulnerable young adults (ie, lower education levels and living below the poverty level). Findings suggest a need for counter-marketing messages, policies that restrict advertising exposure, and educational interventions such as health and media literacy interventions to address the negative influences of tobacco advertisements, especially among young adults with a high school education or less and those living below the poverty level.

Return of cartoon to market e-cigarette-related products.

INTRODUCTION: The tobacco industry's use of cartoons to market products has been shown to be effective at increasing awareness and appeal of combustible cigarettes among youth. While the Master Settlement Agreement placed restrictions on the use of cartoons for major cigarette and smokeless (chew) tobacco brands in the USA, no such restrictions exist for electronic cigarettes (e-cigarettes). Research has shown that e-cigarette manufacturers are using cartoons to market products, but limited data exist on the extent of these practices. This study examined the extent of the use of cartoons to market e-liquids on Instagram. METHODS: Instagram posts with the hashtag #ejuice or #eliquid were collected from 3 November 2017 to 17 November 2017. Rules were established to identify Cartoon (the post contained a cartoon), Logo (the post was labelled a cartoon due to the logo) and Promo (the image of the post or accompanying text indicated it was a promotion) in the data (n=3481). RESULTS: Among all posts, 723 (20.77%) contained a Cartoon, and 479 (13.76%) were coded as a cartoon because of the Logo. In other words, 479/723 or (66.25%) of Cartoon were coded as cartoons due to the vendor's or manufacture's logo. Among all posts, 2360 (67.80%) were Promo. CONCLUSION: Findings indicate that e-cigarette companies are using cartoons to market their products and many of these companies' logos are cartoons. Empirical data are needed to determine whether cartoon marketing strategies impact perceived risk and benefits, product appeal, the intention to use and actual use of e-cigarettes.

Tobacco Use Behaviors, Attitudes, and Demographic Characteristics of Tobacco Opinion Leaders and Their Followers: Twitter Analysis.

BACKGROUND: Tobacco-related content on social media is generated and propagated by opinion leaders on the Web who disseminate messages to others in their network, including followers, who then continue to spread the information. Opinion leaders can exert powerful influences on their followers' knowledge, attitudes, and behaviors; yet, little is known about the demographic characteristics and tobacco use behavior of tobacco opinion leaders on the Web and their followers, compared with general Twitter users. OBJECTIVE: In this study, we hypothesized that opinion leaders use more tobacco products and have higher nicotine dependence than the other 2 groups (eg, followers and general Twitter users) and that followers-those who spread messages by opinion leaders-would more likely be in demographic groups that are vulnerable to tobacco marketing influence (eg, young adults and lower educational attainment). METHODS: We constructed the social networks of people who tweet about tobacco and categorized them using a combination of social network and Twitter metrics. To understand the characteristics of tobacco opinion leaders and their followers, we conducted a survey of tobacco opinion leaders, their followers, and general Twitter users. The sample included 347 opinion leaders, 567 followers, and 519 general users. The opinion leaders had a median of 1000 followers, whereas followers and general users had fewer than 600 followers. RESULTS: Opinion leaders were more likely than their followers to report past month use of tobacco products; followers, in turn, were more likely to report past month use of these products than general Twitter users. The followers appeared to be an especially vulnerable group; they tended to be younger (mean age 22.4 years) and have lower education compared with the opinion leaders and general users. CONCLUSIONS: Followers of Twitter tobacco opinion leaders are a vulnerable group that might benefit from antitobacco education to counter the protobacco communications they see on social media.

Talking about tobacco on Twitter is associated with tobacco product use.

Tobacco-related content appears on social media in the form of advertising and messages by individuals. However, little is known about associations between posting social media messages and tobacco product use among adolescents and young adults. Self-reports of tobacco product use were obtained from the Children's Health Study of young adults in Southern California. Among the 1486 respondents in the most recent wave of the cohort (2016-2017), 284 provided tobacco product use data and their Twitter user names to access publicly available Twitter account data (mean age = 20.1 yrs. (SD = 0.6), 54% female, 49% Hispanic). We obtained the tweets that those respondents posted on Twitter, searched the tweets for 14 nicotine- and tobacco-related keywords, and coded these statements as positive or negative/neutral. Logistic regression analyses were conducted to determine whether respondents who posted positive tobacco-related tweets were more likely to report tobacco product use, relative to those who did not post any positive tobacco-related tweets. Respondents who posted any positive messages about tobacco had significantly higher odds of reporting past month use of cigarettes (OR = 3.15, 95% CI = 1.36, 7.30) and any tobacco product (OR = 2.41, 95% CI = 1.16, 5.01), relative to respondents who did not post about tobacco. This is the first study to establish an empirical link between adolescents' and young adults' tobacco-related Twitter activity and their tobacco product use. Health communications about the risks of tobacco use could target adolescents who post positive messages about tobacco products on Twitter.

Monitoring Tobacco Brand Websites to Understand Marketing Strategies Aimed at Tobacco Product Users and Potential Users.

Introduction: Limited information exists about strategies and methods used on brand marketing websites to transmit pro-tobacco messages to tobacco users and potential users. This study compared age verification methods, themes, interactive activities and links to social media across tobacco brand websites. Methods: This study examined 12 tobacco brand websites representing four tobacco product categories: cigarettes, cigar/cigarillos, smokeless tobacco, and e-cigarettes. Website content was analyzed by tobacco product category and data from all website visits (n = 699) were analyzed. Adult smokers (n = 32) coded websites during a one-year period, indicating whether or not they observed any of 53 marketing themes, seven interactive activities, or five external links to social media sites. Results: Most (58%) websites required online registration before entering, however e-cigarette websites used click-through age verification. Compared to cigarette sites, cigar/cigarillo sites were more likely to feature themes related to "party" lifestyle, and e-cigarette websites were much more likely to feature themes related to harm reduction. Cigarette sites featured greater levels of interactive content compared to other tobacco products. Compared to cigarette sites, cigar/cigarillo sites were more likely to feature activities related to events and music. Compared to cigarette sites, both cigar and e-cigarette sites were more likely to direct visitors to external social media sites. Conclusion: Marketing methods and strategies normalize tobacco use by providing website visitors with positive themes combined with interactive content, and is an area of future research. Moreover, all tobacco products under federal regulatory authority should be required to use more stringent age verification gates. Implications: Findings indicate that the Food and Drug Administration (FDA) should require brand websites of all tobacco products under its regulatory authority use more stringent age verification gates by requiring all visitors be at least 18 years of age and register online prior to entry. This is important given that marketing strategies may encourage experimentation with tobacco or deter quit attempts among website visitors. Future research should examine the use of interactive activities and social media on a wide variety of tobacco brand websites as interactive content is associated with more active information processing.