Electronic cigarette social norms among adolescents in New South Wales, Australia.

The use of electronic cigarettes (e-cigarettes) is common and increasing, especially among youth. In 2022/2023, 30% of 12- to 17-year-olds reported ever using e-cigarettes in Australia-a >50% increase from 2017 (14%). Several adverse e-cigarette health effects have been identified and most effects remain unknown. Social norms, rules that govern social behaviours, are associated with current and future adolescent e-cigarette use. Understanding social norms in Australian adolescents is critical to the development of targeted and effective e-cigarette prevention activities. This study aims to explore e-cigarette social norms among adolescents living in New South Wales, Australia. A total of 32 online single or paired semi-structured qualitative interviews were conducted involving 46 participants aged 14-17 years, as part of the Generation Vape project. Reflexive thematic analysis was applied within a constructivist perceptive. Adolescents perceived e-cigarettes use as prolific among their peers, with use considered common, acceptable and normal. Fuelled by social exposure to e-cigarettes, 'everyone' was generally thought to be using them (descriptive norms). E-cigarette use was considered so entrenched that it was part of adolescent identity, with abstinence regarded as atypical. Use was driven by an internalised desire to fit it (injunctive norm), rather than being attributed to overt/external 'peer-pressure'. Positive e-cigarette norms exist among Australian adolescents with norm formation strongly influenced by social exposure, including e-cigarette promotion. Prevention efforts should include limiting adolescent exposure to e-cigarette marketing to help redefine existing pro-e-cigarette social norms and protect health.

Socio-ecological factors that influence youth vaping: perspectives from Western Australian school professionals, parents and young people.

PURPOSE: To understand from the perspectives of school professionals, parents and young people the socio-ecological factors that may facilitate and prevent e-cigarette use among young people in Perth, Western Australia. METHODS: Purposive sampling was used to recruit school professionals, parents and young people for one-on-one (n = 35) or joint (n = 3) interviews (in-person n = 11 or online n = 27). Data were analysed using thematic analysis and classified into four domains based on the socio-ecological model: i) individual, ii) interpersonal, iii) organizational/community and iv) societal/policy. RESULTS: Factors that were found to support vaping among young people included sensation-seeking and risk-taking behaviour; a low-risk perception of vapes; attractive characteristics of vapes; ease of access; perception vaping is a social activity; and lack of knowledge about vaping among parents and school professionals. Vaping prevention messages originating from the familial, educational and community spheres are lacking but wanted by adults and young people. CONCLUSIONS: The pervasiveness of the e-cigarette trade and persistent challenges related to surveillance and enforcement need to be addressed to reduce exposure and access to e-cigarettes. A mixture of "hard" and "soft" public policy tools involving key stakeholders in a range of settings is needed to prevent e-cigarette access and uptake by young people.

E-cigarettes on Instagram: Exploring vape content via an Australian vaping influencer.

INTRODUCTION: Mounting evidence suggests that electronic cigarettes (e-cigarettes) are extensively promoted and marketed using social media, including through user-generated content and social media influencers. This study explores how e-cigarettes are being promoted on Instagram, using a case-study approach, and the extent to which Meta's Restricted Goods and Services Policy (Meta's policy) is being applied and enforced. METHODS: We identified the accounts followed by an Australian Instagram influencer who primarily posts e-cigarette-related content. The main foci of these 855 accounts were coded and 369 vaping-focused accounts were identified. These vaping-focused accounts were then further coded by two trained coders. RESULTS: All (n=369; 100.0%) of the vape content posted by these accounts was positive in sentiment. One-third of the vape accounts (n=127; 34.4%) had a shared focus, indicating that vape content may permeate into other online communities through shared interests. A total of 64 accounts (17.3%) potentially violated Meta's policy by attempting to purchase, sell, raffle or gift e-cigarette products. CONCLUSIONS: The findings of this study suggest that pro-vaping information is available and accessible on Instagram. Much of the content identified in this study promoted the purchase or gifting of e-cigarette products and potentially violates Meta's policy. Greater regulation and/or stronger enforcement of e-cigarette content on social media platforms such as Instagram is necessary to prevent the ongoing promotion of these harmful products.

Parent's awareness of, and influence on, their 14-17-year-old child's vaping and smoking behaviours; an analysis of 3242 parent-child pairs in Australia.

BACKGROUND: Vaping by young people in Australia is a rapidly emerging public health issue. Evidence shows that parental behaviours and attitudes can play a key role in influencing adolescent behaviours. Considering the health harms of vaping and evidence that it can be a gateway to tobacco smoking for never-smokers, it is important to understand whether parents' smoking and vaping behaviours influence their teenage children's smoking and vaping behaviours. METHODS: Online cross-sectional surveys as part of the Generation Vape study, conducted in Australia in 2021/2022, were used to assess parents' influence on, and awareness of, one of their 14-17-year-old child's vaping and smoking behaviours. Participants were 3242 parents and 3242 14-17-year-old teenage children. RESULTS: The risk of vaping and smoking uptake among 14-17-year-old teenagers was 42% (p = 0.003) and 97% (p < 0.001) higher, respectively, if their parent was an ever-vaper. The risk of vaping and smoking uptake among teenagers was 81% (p < 0.001) and 159% (p < 0.001) higher, respectively, if their parent was an ever-smoker. Parents of teenagers who have not vaped were considerably better at correctly predicting this (97% correct) than parents of teenagers who have vaped (70% correct). Compared to parents, teenagers tended to have less agreement with statements suggesting vaping is unsafe or harmful, and more agreement with statements suggesting vaping is relatively safe. CONCLUSIONS: Parental smoking and vaping behaviours are associated with those of their children. Hence, it is important that both tobacco and vaping control policies and interventions are designed to influence behaviours of all demographics, consistent with the evidence.

National Health and Medical Research Council statement on electronic cigarettes: 2022 update.

INTRODUCTION: Electronic cigarette (e-cigarette) use in Australia has rapidly increased since the 2017 National Health and Medical Research Council (NHMRC) Chief Executive Officer (CEO) statement on e-cigarettes. The type of products available and the demographic characteristics of people using these products have changed. New evidence has been published and there is growing concern among public health professionals about the increased use, particularly among young people who do not currently smoke combustible cigarettes. The combination of these issues led NHMRC to review the current evidence and provide an updated statement on e-cigarettes. In this article, we describe the comprehensive process used to review the evidence and develop the 2022 NHMRC CEO statement on electronic cigarettes. MAIN RECOMMENDATIONS: E-cigarettes can be harmful; all e-cigarette users are exposed to chemicals and toxins that have the potential to cause adverse health effects. There are no health benefits of using e-cigarettes if you do not currently smoke tobacco cigarettes. Adolescents are more likely to try e-cigarettes if they are exposed to e-cigarettes on social media. Short term e-cigarette use may help some smokers to quit who have been previously unsuccessful with other smoking cessation aids. There are other proven safe and effective options available to help smokers to quit. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: The evidence base for the harms of e-cigarette use has strengthened since the previous NHMRC statement. Significant gaps in the evidence base remain, especially about the longer term health harms of using e-cigarettes and the toxicity of many chemicals in e-cigarettes inhaled as an aerosol.

Exploring motivations for engagement with the Healthy Lunch Box campaign on social media.

Many health organisations seek social media engagement through their online health promotion campaigns, but there is little understanding of what engagement means in relation to the uptake of health messages. To understand the relevance of social media engagement, we need to look at the reasons why people engage with health content via social media. This exploratory study examined people's motivations for engaging with health content through a case study of the Healthy Lunch Box campaign. Data was collected via online focus groups (n = 7), with participants being a convenience sample of people who had seen or engaged with the Healthy Lunch Box resources (n = 24). The discussions covered reasons for engaging with the Healthy Lunch Box campaign, and more broadly with health content on social media in general. The data was analysed using a reflexive approach to thematic analysis, with themes developed inductively. The study found that some of the reasons for engagement aligned with the paradigm of social media engagement being an intermediary step in the process towards health behaviour change. However, people also described other reasons, such as alignment with their personal values, consideration of their online presentation, or as a way of curating the content they wanted to be shown on social media. These results demonstrate that people's decision to engage with health-related social media content involves more than consideration about the usefulness of the content, suggesting the need for a deeper examination of the assumptions made about the value of social media engagement in health campaign evaluations.

A Model of Social Media Effects in Public Health Communication Campaigns: Systematic Review.

BACKGROUND: Social media platforms are frequently used in health communication campaigns. Common understandings of campaign effects posit a sequential and linear series of steps from exposure to behavior change, commonly known as the hierarchy of effects model (HOE). These concepts need to be reevaluated in the age of social media, which are interactional and communal. OBJECTIVE: This review aims to update the traditional HOE for health communication campaigns in the context of social media, including identifying indicators of effectiveness and how these are conceptualized to lead to health-related outcomes. METHODS: We conducted a systematic review of studies following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines reporting on the use of social media as part of health communication campaigns, extracting campaign information such as objectives, platforms used, and measures of campaign performance. We used these data, combined with our understanding of the HOE, to develop an updated conceptual model of social media campaign effects. RESULTS: We identified 99 eligible studies reporting on 93 campaigns, published between 2012 and 2022. The campaigns were conducted in over 20 countries, but nearly half (n=42) were conducted in the United States. Campaigns targeted a variety of health issues and predominantly used Facebook, Twitter, Instagram, and YouTube. Most campaigns (n=81) set objectives targeting awareness or individual behavior change. Process measures (n=68; eg, reach and impressions) and engagement measures (n=73; eg, likes and retweets) were reported most frequently, while two-fifths (n=42) did not report any outcomes beyond engagement, such as changes in knowledge, behavior, or social norms. Most campaigns (n=55) collected measures that did not allow them to determine if the campaign objective had been met; that is, they were process evaluations only. Based on our review, our updated model suggests that campaign exposure can lead to individual behavior change and improved health outcomes, either through a direct or indirect pathway. Indirect pathways include exposure through social and policy changes. "Engagement" is positioned as critical to success, replacing awareness in the traditional HOE, and all types of engagement are treated as equal and good. No consideration is being given to potential negative engagement, such as the distribution of misinformation. Additionally, the process is no longer linear and sequential, with circular pathways evident, such as engagement not only influencing behavior change but also generating additional exposure to campaign messages. CONCLUSIONS: Our review has highlighted a change in conventional understandings of how campaigns can influence health outcomes in the age of social media. The updated model we propose provides social media campaigners with a starting point to develop and tailor campaign messages and allows evaluators to identify critical assumptions to test, including the role and value of "engagement." TRIAL REGISTRATION: PROSPERO CRD42021287257; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=287257.

From the international tobacco control arena to the local context: a qualitative study on the tobacco advertising, promotion and sponsorship legislative environment in Sudan and the challenges characterising it.

OBJECTIVES: The aim of the study was to assess the Sudanese tobacco advertising, promotion and sponsorship (TAPS) legislative environment and the challenges characterising it. We formulated three research questions: What is the TAPS policy context in Sudan? What circumstances led to the development of the current legislative text? Finally, what was the involvement of the different actors in these events? DESIGN: We conducted a qualitative analysis using the Health Policy Triangle model to frame the collection and extraction of publicly available information from academic literature search engines, news media databases or websites of national and international organisations, as published by February 2021. The thematic framework approach was employed to code and analyse the textual data and the generated themes were used to map connections across the data and to explore relationships among the generated subthemes and themes. SETTING: Sudan. DATA: Using a combination of the keywords "Sudan" and "tobacco advertising" (or "tobacco marketing" or "tobacco promotion"), we collected publicly available documents in the English language. We included 29 documents in the analysis. RESULTS: Three themes underpin the Sudanese legislative environment on TAPS: (1) limited and outdated TAPS data, (2) stakeholder involvement and tobacco industry interference and (3) TAPS legislation not aligned with the WHO Framework Convention on Tobacco Control Secretariat recommendations. CONCLUSIONS: Findings from this qualitative analysis suggest that recommendations to move forward in Sudan should include the systematic and periodic collection of TAPS surveillance data, addressing any remaining legislative content loopholes and protecting policy-making from tobacco industry interference. In addition, best practices from other low-income and middle-income countries with good TAPS monitoring systems, such as Egypt, Bangladesh and Indonesia, or with protective provisions against tobacco industry interference, such as Thailand and the Philippines, could be considered for adaptation and implementation.

Promotion of E-Cigarettes on TikTok and Regulatory Considerations.

E-cigarettes are promoted extensively on TikTok and other social media platforms. Platform policies to restrict e-cigarette promotion seem insufficient and are poorly enforced. This paper aims to understand how e-cigarettes are being promoted on TikTok and provide insights into the effectiveness of current TikTok policies. Seven popular hashtag-based keywords were used to identify TikTok accounts and associated videos related to e-cigarettes. Posts were independently coded by two trained coders. Collectively, the 264 videos received 2,470,373 views, 166,462 likes and 3426 comments. The overwhelming majority of videos (97.7%) portrayed e-cigarettes positively, and these posts received 98.7% of the total views and 98.2% of the total likes. A total of 69 posts (26.1%) clearly violated TikTok's own content policy. The findings of the current study suggest that a variety of predominantly pro-vaping content is available on TikTok. Current policies and moderation processes appear to be insufficient in restricting the spread of pro-e-cigarette content on TikTok, putting predominantly young users at potential risk of e-cigarette use.

Achieving a tobacco-free Bangladesh by 2040: a qualitative analysis of the tobacco advertising environment and prohibitions in Bangladesh.

OBJECTIVES: This paper explores the Bangladeshi tobacco advertising, promotion and sponsorship (TAPS) legislative environment, to highlight any potential policy loopholes and to facilitate the identification of additional provisions for inclusion. The study also aimed to identify valuable lessons applicable to other low-income and middle-income countries (LMICs). METHODS: We conducted a qualitative health policy analysis using the health policy triangle model to frame the collection and extraction of publicly available information from academic literature search engines, news media databases and websites of national and international organisations, published up until December 2020. We coded and analysed textual data using the thematic framework approach to identify themes, relationships and connections. RESULTS: Four themes underpin the Bangladesh legislative environment on TAPS: (1) engaging international actor interest in TAPS policies, (2) the incremental approach to TAPS policy-making, (3) time-sensitive TAPS monitoring data and (4) innovative TAPS monitoring and policy enforcement system. The findings highlight the role of international actors (such as multinational organisations and donors), tobacco control advocates and the tobacco industry in the policy-making process and the competing agendas they bring. We also outline the chronology of TAPS policy-making in Bangladesh and the existing loopholes and policy changes over time. Lastly, we describe the innovative approaches to TAPS monitoring and policy enforcement in Bangladesh to combat the tobacco industry marketing strategies. CONCLUSION: This study highlights the role of tobacco control advocates as crucial in TAPS policy-making, monitoring and enforcement in LMICs, and identifies good practices for the sustainability of tobacco control programmes. However, it also points out that tobacco industry interference, coupled with increasing pressure on advocates and legislators, may block progress in tobacco endgame approaches.

How tobacco companies use the revolving door between government and industry to influence policymaking: an Australian case study.

Objectives and importance of the study: The study investigates and documents how tobacco companies are using the revolving door between government and industry as a tactic to try to influence public health policymaking in Australia. This is the first Australian study to systematically investigate the revolving door tactic in tobacco lobbying and highlights the importance of strengthening integrity and transparency legislation and oversight bodies to eliminate the political influence of tobacco companies in Australia. STUDY TYPE: Mixed-methods including non-experimental descriptive and exploratory case studies. METHODS: To build a picture of tobacco lobbying through the revolving door in Australia, data was triangulated from multiple publicly available sources: 1) Australian federal, state and territory government lobbyist registers, 2) the online social networking platform, LinkedIn; and 3) Australian news media reports. RESULTS: Tobacco companies lobby the Australian government using 'in-house' employees, lobbyists working in firms acting on their behalf, and third-party allies with common interests. Almost half (48%) of internal tobacco company lobbyists had held positions in the Australian government (state, territory and/or federal) before or after working in the tobacco industry. Likewise, 55% of lobbyists acting on behalf of tobacco companies had held government positions before or after working as a lobbyist. In-house tobacco industry lobbyists, as well as those working on behalf of tobacco companies within lobbying firms, were found to have held senior governmental positions, such as a Member of Parliament (MP) or Senator, chief or deputy chief of staff, or senior advisor in a ministerial office, and many had moved into or out of government within 1 year of working for a tobacco company (56%) or as a lobbyist (48%). CONCLUSIONS: Tobacco companies are strategically using the revolving door between the government and the tobacco industry as a key political lobbying mechanism to try to influence public health policy in Australia.

Study protocol of the Our Futures Vaping Trial: a cluster randomised controlled trial of a school-based eHealth intervention to prevent e-cigarette use among adolescents.

BACKGROUND: Effective and scalable prevention approaches are urgently needed to address the rapidly increasing rates of e-cigarette use among adolescents. School-based eHealth interventions can be an efficient, effective, and economical approach, yet there are none targeting e-cigarettes within Australia. This paper describes the protocol of the OurFutures Vaping Trial which aims to evaluate the efficacy and cost-effectiveness of the first school-based eHealth intervention targeting e-cigarettes in Australia. METHODS: A two-arm cluster randomised controlled trial will be conducted among Year 7 and 8 students (aged 12-14 years) in 42 secondary schools across New South Wales, Western Australia and Queensland, Australia. Using stratified block randomisation, schools will be assigned to either the OurFutures Vaping Program intervention group or an active control group (health education as usual). The intervention consists of four web-based cartoon lessons and accompanying activities delivered during health education over a four-week period. Whilst primarily focused on e-cigarette use, the program simultaneously addresses tobacco cigarette use. Students will complete online self-report surveys at baseline, post-intervention, 6-, 12-, 24-, and 36-months after baseline. The primary outcome is the uptake of e-cigarette use at 12-month follow-up. Secondary outcomes include the uptake of tobacco smoking, frequency/quantity of e-cigarettes use and tobacco smoking, intentions to use e-cigarettes/tobacco cigarettes, knowledge about e-cigarettes/tobacco cigarettes, motives and attitudes relating to e-cigarettes, self-efficacy to resist peer pressure and refuse e-cigarettes, mental health, quality of life, and resource utilisation. Generalized mixed effects regression will investigate whether receiving the intervention reduces the likelihood of primary and secondary outcomes. Cost-effectiveness and the effect on primary and secondary outcomes will also be examined over the longer-term. DISCUSSION: If effective, the intervention will be readily accessible to schools via the OurFutures platform and has the potential to make substantial health and economic impact. Without such intervention, young Australians will be the first generation to use nicotine at higher rates than previous generations, thereby undoing decades of effective tobacco control. TRIAL REGISTRATION: The trial has been prospectively registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12623000022662; date registered: 10/01/2023).

COVID-19 messages targeting young people on social media: content analysis of Australian health authority posts.

Health authorities utilized social media during the COVID-19 pandemic to disseminate critical and timely health messages, specifically targeting priority groups such as young people. To understand how social media was used for this purpose, we investigated the content of COVID-19-related social media posts targeting young people (16-29 years old) shared by Australian health departments. Posts targeting young people with COVID-19 information were extracted from all eight Australian State and Territory health department Facebook, Instagram and TikTok accounts over 1 month of the Delta outbreak (September 2021) and analysed thematically. In total, 238 posts targeting young people were identified from 1059 COVID-19 posts extracted. All eight health departments used Facebook, five used Instagram and only one used TikTok. The majority of posts implicitly targeted young people; only 14.7% explicitly mentioned age or 'young people'. All posts included accompanying visuals; 77% were still images like photos or illustrations whilst 23% were moving images like videos and GIFs. Communication techniques included calls to action (63% of posts), responsive communication (32% of posts) and positive emotional appeal (31% of posts). Social marketing techniques catering to young people were used to varying extents despite receiving higher levels of engagement; 45% featured emojis whilst only 16% used humour, 14% featured celebrities and 6% were memes. Priority groups like ethnic/cultural groups and chronic health/disability communities were rarely targeted in this communication. The findings indicate a lack of health communication on social media directed towards young people, highlighting an opportunity for increased use of platforms like TikTok and trends popular with young people online.

Reigniting tobacco control: returning Australia to the front of the pack.

Australia has long been heralded as a leader in tobacco control, but more than 10 years have passed since the country implemented the world's first tobacco plain packaging reforms. In late 2022, the Australian Federal Government announced it would be "reigniting the fight against tobacco addiction". The forthcoming reforms package will help modernise and re-energise Australian tobacco control. The Government has signalled that preliminary reforms will include updating graphic health warnings, standardising tobacco pack sizes and filters, and banning menthol and flavours. The recently endorsed National Tobacco Strategy 2023-2030 also opens the door to further supply-side reforms. Ten years ago, when Australia fought multiple legal challenges from the tobacco industry and established plain packaging as a best practice standard, e-cigarette or vaping products were a fringe issue with little presence in Australia. Today, vaping product use by young Australians has dramatically and rapidly increased. Easy access and marketing of cheap, flavoured, disposable, nicotine-containing vaping products are driving use. Recognising that the current approach to e-cigarette regulation is not achieving its aim of preventing children and adolescents from accessing vaping products, the Australian Therapeutic Goods Administration (TGA) launched a consultation on possible reforms in late 2022. Currently, vaping importers and retailers are exploiting an exemption for non-nicotine products in regulations, and nicotine-containing products are masquerading as non-nicotine products. The ideal public health solution would see the elimination of all vaping product sales, nicotine and non-nicotine alike, that fall outside of the TGA prescription-only access pathway. After 10 years of minimal action, it is invigorating to have three key initiatives in play to fully "reignite" tobacco control - the tobacco legislation renewal and update, the imminent national strategy release, and the TGA consultation on vaping products. Re-establishing Australia as a tobacco control leader is welcome news for public health.

An analysis of key stakeholder policy perspectives in the proposed e-cigarette regulations in New Zealand.

ISSUE ADDRESSED: The use of e-cigarettes is increasing; New Zealand (NZ) has witnessed a rapid rise in consumption. Policymakers face a challenge to balance the impacts of regulation on those who use e-cigarettes as a smoking cessation tool while protecting people who do not smoke from the harms of e-cigarette use, particularly young people. Previous research has demonstrated varying perspectives on e-cigarette regulation according to different stakeholders and interest groups. This study examined key stakeholders' positions on the drafted legislation to regulate e-cigarettes in NZ. METHODS: Using written submissions made during public consultation in 2020, we conducted a content analysis to determine levels of support for e-cigarette regulations. Submissions made by the e-cigarette industry and the health sector were included for analysis. RESULTS: The tobacco industry is heavily invested in ensuring that e-cigarettes continue to be promoted and available in NZ with minimal restrictions. On the contrary, health organisations supported the introduction of regulations to reduce marketing to, and use of e-cigarettes by youth and people who do not smoke. CONCLUSIONS: The industry opposes restrictions using similar approaches employed against tobacco control measures. Despite perceptions of division, the health sector is generally unified in support of e-cigarette restrictions. SO WHAT?: Policymakers must protect public health policies from commercial interests and be cautious of opposition framed as public health concerns.