Young Adults' Experiences with Cannabis Retailer Marketing and Related Practices: Differences Among Sociodemographic Groups and Associations with Cannabis Use-related Outcomes.

OBJECTIVES: Limited cannabis retail surveillance has been conducted, particularly assessing retailer practices in relation to consumer sociodemographic factors or use-related outcomes. This study examined young adults': exposure to promotions, health claims, warnings, and age restrictions at cannabis retailers; demographic correlates of retail exposures; and retail exposures in relation to use-related outcomes. STUDY DESIGN: This study used the cross-sectional quantitative analysis. METHODS: We analyzed 2023 survey data among 876 young adults in states with legal non-medical cannabis, reporting past-month cannabis use and past-year retailer visits. RESULTS: In this sample (Mage = 27.1, 44.1% male, 31.7% sexual minority, 17.7% Black, 11.2% Asian, 25.1% Hispanic), 46.7% "at least sometimes" noticed free samples, 76.5% price promotions, 37.4% subpopulation-targeted promotions; 72.5% health claims on products/ads, 63.1% signage, and 70.5% from budtenders; 72.5% warnings on labels, 65.5% signage, and 38.9% from budtenders; and > 80% age verifications. Multivariable analyses identified sociodemographic correlates of exposure outcomes: greater promotion exposure was associated with Black race; greater health claim exposure with being heterosexual, Black, and less educated; less warning exposure with less education; and less age restriction exposure with being younger, male, and Black. Retail exposures were associated with use-related outcomes: more frequent cannabis use was associated with less health claim exposure; greater perceived social acceptability with greater promotion and age restriction exposure; greater perceived risk with greater warning and less age restriction exposure; more problematic use and driving after use with greater promotion and less age restriction exposure. CONCLUSIONS: Cannabis retail exposure disparities and their associations with use-related outcomes highlight the importance of regulatory and prevention efforts.

Low compliance and proliferation of IQOS purchase cues at points-of-sale: a comparative study before and after Israel's display ban.

INTRODUCTION: It is unclear how tobacco companies respond to increasing restrictions on points-of-sale (POS) (eg, advertisement ban, display ban), especially regarding newer products, such as IQOS, a heated tobacco product. This study compared POS marketing strategies for IQOS (and HEETS tobacco sticks) before and after Israel implemented a display ban and plain packaging. METHODS: Audits of stores selling IQOS (n=87) in four Israeli cities were conducted, 16-20 months post display ban and plain packaging introduction, including previously audited stores (n=60) (prior to the implementation of these measures). Descriptive analyses and matched pre-post comparisons were conducted to assess regulatory compliance and marketing strategies over time. RESULTS: Almost all stores (90.8%) were non-compliant with the display ban; but most were compliant with plain packaging (81.6%) and advertisement ban (83.5%) regulations. Following the display ban, there was a significant increase in the number of IQOS/HEETS internal advertisements (21.7% vs 41.7%, p=0.023). These were mostly compliant with the advertisement ban (ie, did not mention the brand name explicitly), and appeared in the form of generic signs or flags and/or special displays. The percentage of stores featuring the IQOS device increased (1.7% to 20.0%, p=0.003), as did the percentage carrying at least four HEETS flavours (36.7% to 63.3%, p=0.006). CONCLUSION: This sample of Israeli stores selling IQOS showed low compliance with the display ban. The increase in signs/special displays, mostly compliant with the advertisement ban, could serve as purchase cues circumventing the intent of the legislation. Regulatory efforts should consider more specific legislative language and comprehensive enforcement plans.

The inclusion of e-cigarettes and heated tobacco products in smoke-free home and car rules: A cross-sectional survey of adults in Armenia and Georgia.

INTRODUCTION: Understanding who includes e-cigarettes and heated tobacco products (HTPs) in smoke-free home or car rules could inform public health interventions, particularly in countries with high smoking prevalence and recently implemented national smoke-free laws, like Armenia and Georgia. METHODS: In 2022, we conducted a cross-sectional survey among 1468 adults in 28 Armenian and Georgian communities (mean age=42.92 years; 51.4% female, 31.6% past-month smoking). Multilevel regression (accounting for clustering within communities; adjusted for sociodemographics and cigarette use) examined e-cigarette/HTP perceptions (risk, social acceptability) and use intentions in relation to: 1) including e-cigarettes/HTPs in home and car rules among participants with home and car rules, respectively (logistic regressions); and 2) intention to include e-cigarettes/HTPs in home rules (linear regression, 1 = 'not at all' to 7 = 'extremely') among those without home rules. RESULTS: Overall, 72.9% (n=1070) had home rules, 86.5% of whom included e-cigarettes/HTPs; 33.9% (n=498) had car rules, 81.3% of whom included e-cigarettes/HTPs. Greater perceived e-cigarette/HTP risk was associated with including e-cigarettes/HTPs in home rules (AOR=1.28; 95% CI: 1.08-1.50) and car rules (AOR=1.46; 95% CI: 1.14-1.87) and next-year intentions to include e-cigarettes/HTPs in home rules (ß=0.38; 95% CI: 0.25-0.50). Lower e-cigarette/HTP use intentions were associated with including e-cigarettes/HTPs in home rules (AOR=0.75; 95% CI: 0.63-0.88). While perceived social acceptability was unassociated with the outcomes, other social influences were: having children and no other household smokers was associated with including e-cigarettes/HTPs in car rules, and having children was associated with intent to include e-cigarettes/HTPs in home rules. CONCLUSIONS: Interventions to address gaps in home and car rules might target e-cigarette/HTP risk perceptions.

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

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

Impact of exposures to Heated Tobacco Products in the media and through social connections on product perceptions and use.

INTRODUCTION: Little is known about media exposures to heated tobacco products (HTPs). In this study, we examined sources of HTP exposure, including from paid and unpaid media and social connections, in relation to HTP use and use intentions. METHODS: In the fall of 2021, we conducted a cross-sectional survey among adult online panelists (aged 18-45 years) in the US and Israel, oversampling tobacco users. The current study analyzed data from participants who responded to the question about HTP awareness or use (n=2061). Multivariable linear and logistic regression analyses examined the relationship between sources of HTP exposure, HTP use, and use intentions. RESULTS: Among those aware of HTPs, both Israelis and Americans reported past-month HTP media exposure via advertisements (58.2% vs 48.0%), non-advertisement sources (49.7% vs 30.7%), and social connections (51.5% vs 33.6%), respectively. Factors associated with HTP awareness (n=677/2061; 32.9%) included media use frequency (AOR=1.13; 95% CI: 1.01-1.28) and social connections using HTPs (AOR=2.45; 95% CI: 1.92-3.15). Among those aware of HTPs, past-month HTP exposure via digital media advertisements (AOR=2.06; 95% CI: 1.09-3.91) and non-advertising promotion via radio, podcast, movie, television or theatre (AOR=2.30; 95% CI: 1.19-4.44) and websites (AOR=2.36; 95% CI: 1.32-4.21) were associated with current HTP use. Exposure to digital media advertisements (ß=0.35; 95% CI: 0.07-0.62) and non-advertising promotion via social media (ß=0.62; 95% CI: 0.34-0.91) were correlated with higher use intentions. Having social connections using HTPs was correlated with higher use (AOR=2.21; 95% CI: 1.19-4.11) and intentions (ß=0.66; 95% CI: 0.42-0.91). No significant differences were found across countries. CONCLUSIONS: Digital media (e.g. online, social media) were particularly salient correlates of HTP intentions and use. Future studies are needed that further examine media exposures to these products, as well as that examine possible regulations to limit HTP promotion via these channels.

Heated tobacco product marketing: a mixed-methods study examining exposure and perceptions among US and Israeli adults.

The marketing of heated tobacco products (HTPs), like IQOS, influences consumers' perceptions. This mixed-methods study analyzed (i) survey data (2021) of 2222 US and Israeli adults comparing perceptions of 7 IQOS attributes (design, technology, colors, customization, flavors, cost and maintenance) and 10 marketing messages (e.g. 'Go smoke-free…') across tobacco use subgroups and (ii) qualitative interviews (n = 84) regarding IQOS perceptions. In initial bivariate analyses, those never using HTPs (86.2%) reported the least overall appeal; those currently using HTPs (7.7%) reported the greatest appeal. Notably, almost all (94.8%) currently using HTPs also currently used cigarettes (82.0%) and/or e-cigarettes (64.0%). Thus, multivariable linear regression accounted for current cigarette/e-cigarette use subgroup and HTP use separately; compared to neither cigarette/e-cigarette use (62.8%), cigarette/no e-cigarette use (17.1%) and e-cigarette/no cigarette use (6.5%), those with dual use (13.5%) indicated greater overall IQOS appeal (per composite index score); current HTP use was not associated. Qualitative data indicated varied perceptions regarding advantages (e.g. harm, addiction and complexity) of IQOS versus cigarettes and e-cigarettes, and perceived target markets included young people, those looking for cigarette alternatives and females. Given the perceived target markets and particular appeal to dual cigarette/e-cigarette use groups, IQOS marketing and population impact warrant ongoing monitoring to inform regulation.

Changes in online marketing and sales practices among non-medical cannabis retailers in 5 US cities, 2022 to 2023.

Objectives: Given the evolving cannabis marketplace (e.g., products, marketing strategies), this study examined online cannabis marketing practices over time. Methods: In 2022 and 2023, researchers assessed website content (e.g., age verification, sales, delivery, warnings, ad content, promotional strategies) among 175 randomly-selected cannabis retailers' websites across 5 US cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles [LA], California, n=∼35/city). Analyses compared data from 2022 vs. 2023 and considered regulatory factors across cities. Results: Similar to 2022, in 2023, 76.6 % required age verification for site entry, 85.1 % used social media promotion, and 90.9 % offered online sales (82.4 % of which required age verification and 34.6 % offered delivery). There were significant (p < .05) decreases from 2022 to 2023 in the proportions indicating medical card requirements (27.4 % to 15.4 %), purchase limits (59.4 % to 47.4 %), health warnings (38.9 % to 29.7 %), health benefits (60 % to 47.4 %), and discounts/price promotions (92.6 % to 86.3 %). In 2023, proportions differed across cities in ways reflecting whether state/local law allowed online sales (>90 % in Denver, Las Vegas, LA), allowed discounts/price promotions (100 % in Denver and Las Vegas), or required health warnings (48-60 % in Seattle and LA vs. < 20 % elsewhere). Despite all sites prohibiting youth-oriented content and all but Denver and Las Vegas prohibiting health claims, 30.3 % posted content targeting youth/young adults (LA = 8.1 % to Denver = 74.2 %) and 47.4 % health claims (Seattle = 27.0 % to Denver = 71.0 %). Conclusions: Online cannabis retail presents risks for access and appeal to minors, emphasizes health benefits, and uses price promotions, regardless of restrictions, indicating need for greater regulatory efforts.

Perceptions of Heated Tobacco Products (HTPs) vs. Cigarettes and E-Cigarettes in Relation to Likelihood of Trying HTPs or Suggesting HTPs to Those Who Smoke Cigarettes.

INTRODUCTION: Heated tobacco products (HTPs), like IQOS, are marketed as innovative, stylish, harm-reduction products distinct from cigarettes and e-cigarettes. Research is needed to better understand how adults who are newly introduced to HTPs perceive them relative to cigarettes and e-cigarettes, and the impact of these perceptions on use outcomes. METHODS: We analyzed 2021 cross-sectional survey data from 1,914 adults who never used HTPs from the United States and Israel, two countries where IQOS has unique histories and markets. Exploratory factor analysis examined perceptions of HTPs (vs. cigarettes and e-cigarettes) across 12 perception measures (e.g., innovative, trendy, harmful, addictive). Multivariable linear regression examined these factors in relation to self-reported likelihood to: 1) "try HTPs in the next year" (1=not-7=extremely); and 2) "suggest IQOS to a friend who smokes cigarettes" (1=not-5=very), controlling for demographics and past-month cigarette and e-cigarette use (10.1% dual use, 15.4% cigarette-only, 5.7% e-cigarette-only, 68.8% neither). RESULTS: Four factors were identified: HTPs' health and utility ('health-utility') and design and appeal ('design-appeal') vs. cigarettes and vs. e-cigarettes, separately. More favorable perceptions of HTP vs. e-cigarette design-appeal (B=0.30, 95%CI=0.18, 0.41) was associated with greater likelihood to try HTPs. More favorable perceptions of HTP vs. cigarette design-appeal (B=0.38, 95%CI=0.26, 0.51) and health-utility (B=0.25, 95%CI=0.13, 0.36), and HTP vs. e-cigarette design-appeal (B=0.32, 95%CI=0.20, 0.45) were associated with greater likelihood to suggest HTPs to smokers. CONCLUSIONS: Monitoring perceptions of HTPs vs. cigarettes and e-cigarettes is critical given the role of such perceptions in HTP use and their population-level impact. IMPLICATIONS: This study examined the relationship of perceptions of HTPs relative to cigarettes and e-cigarettes, with regard to adults' self-reported likelihood to use HTP or to suggest HTPs to those who smoke cigarettes. Favorable perceptions of HTPs' design and appeal versus e-cigarettes correlated with greater likelihood to try HTPs. Favorable perceptions of HTPs' design and appeal, as well as health and utility, versus cigarettes and e-cigarettes correlated with greater likelihood to suggest HTPs to those who smoke. Findings underscore the need for ongoing surveillance of HTP marketing and consumer perceptions to inform regulatory efforts and estimate the population-level impact of HTPs and other tobacco products.

Two-part models identifying predictors of cigarette, e-cigarette, and cannabis use and change in use over time among young adults in the US.

BACKGROUND AND OBJECTIVES: Limited longitudinal research has examined differential interpersonal and intrapersonal correlates of young adult use and use frequency of cigarettes, e-cigarettes, and cannabis. This study aimed to address these limitations. METHODS: We analyzed five waves of longitudinal data (2018-2020) among 3006 US young adults (Mage = 24.55, 44% male, 32% sexual minority, ~30% racial/ethnic minority). Two-part latent growth models examined likelihood of past-month cigarette, e-cigarette, and cannabis use (binary part) and days used (continuous part) and identified predictors (depressive symptoms, personality traits, adverse childhood experiences [ACEs], parental use) of baseline use and changes over time. RESULTS: Regarding baseline past-month use (27% cigarettes, 38% e-cigarettes, 39% cannabis), depressive symptoms, ACEs, and parental substance use predicted use outcomes (i.e., likelihood, frequency) for each product; extraversion predicted cigarette and e-cigarette use outcomes; openness predicted e-cigarette and cannabis use outcomes; conscientiousness negatively predicted cigarette and cannabis use outcomes; and agreeableness negatively predicted cannabis use frequency. Regarding longitudinal changes, conscientiousness predicted accelerated increase of cigarette use frequency at later timepoints; depressive symptoms predicted increases in likelihood of e-cigarette use but the association weakened over time; and parental cannabis use predicted decreased cannabis use frequency but the association weakened over time. DISCUSSION AND CONCLUSIONS: Young adult substance use interventions should target high-risk subgroups and focus on distinct factors impacting use, including chronic, escalating, and decreasing use. SCIENTIFIC SIGNIFICANCE: This study advances the literature regarding distinct predictors of different substance use outcomes and provides unique data to inform interventions targeting young adult cigarette, e-cigarette, and cannabis use.

IQOS point-of-sale marketing: a comparison between Arab and Jewish neighborhoods in Israel.

Background: Philip Morris International's (PMI) IQOS, with its heatsticks (HEETS), is the heated tobacco product with the largest global market share. IQOS and/or electronic cigarettes use rate is higher among Arabs vs. Jews in Israel. This paper aims to compare IQOS point-of-sale (POS) marketing strategies, and regulatory compliance in Arab vs. Jewish neighborhoods in Israel. Methods: We integrated data from two separate studies including a cross-sectional survey with IQOS retailers (December 2020-April 2021) and audits of POS that sold IQOS/HEETS (April 2021-July 2021) in 5 large cities in Israel, after marketing restrictions including a POS display ban and plain packaging became effective in Israel (January 2020). The survey included 69 POS (21 Arab, 48 Jewish neighborhoods) and the audits included 129 POS (48 Arab, 81 Jewish neighborhoods). Comparisons of IQOS marketing strategies between POS in Arab and Jewish neighborhoods were conducted using Chi-Square test, Fisher's exact test or Mann-Whitney test, as appropriate. Thematic analysis was used to analyze open-ended questions. Results: Most marketing strategies, such as promotions to customers, were uniform across POS in Arab and Jewish neighborhoods. The most noteworthy differences were that a higher proportion of retailers from Arab neighborhoods were invited to IQOS parties (47.6% vs. 21.7%, p<0.05) and reported personal communication with a PMI representative (80.0% vs. 51.2%, p<0.05). Additionally, PMI representatives assisted POS in both Arab and Jewish neighborhoods in implementing the display ban by providing free compliant cabinets and product placement instructions, and directly interacted with customers. POS in Arab neighborhoods were more compliant with the display ban (25.5% vs. 8.8%, p<0.05), but less compliant with plain packaging (62.5% vs. 79.3%, p<0.05). Conclusions: There were not many notable differences in IQOS marketing across POS in Arab vs. Jewish neighborhoods, but PMI utilized marketing elements of cultural significance, especially for POS in Arab neighborhoods, such as more personal communication and invitation to social events. Continuous surveillance of tobacco POS marketing and legislation compliance is needed, with a special focus on demographic/location-based differences.

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

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

Cannabis Retailer Communication About Cannabis Products, Health Benefits, and Risks: A Mystery Shopper Study of Licensed Retailers in Five U.S. Cities.

OBJECTIVE: As the U.S. cannabis market expands, surveillance of retailer practices, especially product health claims and risks, is crucial to protect consumers. In this study, mystery shoppers (i.e., staff not explicitly identified as researchers) examined retail personnel communication regarding product recommendations, health benefits, safety, and/or risks among U.S. cannabis retailers. METHOD: In Summer 2022, mystery shoppers audited 140 licensed cannabis retailers in 5 cities in states with established nonmedical (i.e., recreational) cannabis sales and diverse regulations (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California). Descriptive and bivariate analyses characterized retail personnel communication overall and across cities. RESULTS: Common product recommendations for new users included edibles, pre-rolled joints, and bud/flower, and 8.6% offered free/inexpensive ways to sample products. Although Colorado, Washington, and Oregon explicitly prohibited health claims in advertising or labels, more than 90% of retailers there endorsed use for anxiety, insomnia, and/or pain. Whereas 54.3% endorsed use for pregnancy-related nausea (least common in Denver, 23.3%; most common in Seattle, 76.7%), 26.4% warned against use during pregnancy (most frequently in Denver, 46.7%; least frequently in Seattle and Portland, 13.3%). Overall, 52.1% warned against driving after use (most frequently in Denver, 80.0%; least frequently in Las Vegas, 20.0%). Almost all (≥90%) sold cannabidiol (CBD) products and endorsed their health benefits and safety, but few (<10%) sold or endorsed delta-8 tetrahydrocannabinol (THC), etc. (all of which were in Los Angeles). CONCLUSIONS: Ongoing cannabis retail surveillance, particularly using protocols assessing factors outside those visibly observable, is needed to inform regulatory and enforcement efforts, especially related to health claims.

Health warning labels on heated tobacco products and their impact on use intentions and risk perceptions: a cross-sectional study of adult tobacco users in the US and Israel.

BACKGROUND: Health warning labels (HWLs) represent an evidence-based tobacco control strategy; however, their application to heated tobacco products (HTPs) and related impacts are understudied. This study examined the impact of HTP HWLs on HTP use intentions and risk perceptions among current tobacco users. METHODS: We analyzed cross-sectional survey data from adults in the US and Israel reporting past-month tobacco use and awareness of HTPs (N = 424). Multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of HTP HWLs (i.e., more concerned about HTP use, reassured, no effect [referent]) among those who noticed HTP HWLs (multinomial regressions); and (2) HWL impacts in relation to HTP use intentions and perceived addictiveness and harm (linear regressions). RESULTS: Among participants who noticed HTP HWLs (n = 372, 87.7%), 27.7% reported HWLs increased their concerns about HTP use, 22.6% were reassured about use, and 49.7% reported no effect. Factors associated with increased concern (vs. no effect) included other tobacco product use (aOR = 2.10, 95% CI 1.21-3.64) and being female (aOR = 1.77, 95% CI 1.03-3.05). Factors associated with being reassured about HTPs use (vs. no effect) included current HTP use (aOR = 2.11, 95% CI 1.11-4.00) and being from Israel (vs. US: aOR = 3.85, 95% CI 1.85-7.69), female (aOR = 1.91, 95% CI 1.07-3.42), and less educated (< college education: aOR = 2.57, 95% CI 1.42-4.63). Reporting that HWLs on HTPs increased concern (ß = 0.46, 95% CI 0.03-0.89) and reassured of use (ß = 0.94, 95% CI 0.47-1.41) were positively associated with HTP use intentions; no associations with risk perceptions were found. CONCLUSIONS: Findings indicate that most tobacco users noticed HWLs on HTPs, but the majority reported no effect or being reassured of using HTPs, effects that were magnified for specific subgroups. Both increased concern and reassurance correlated with greater use intentions. Additional research should evaluate HTP HWL impacts and ensure effectiveness in communicating risks and discouraging use.

The impacts of electronic cigarette health warning labels on use intentions and perceptions: A cross-sectional study of US and Israeli adults who use tobacco.

Background: Health warning labels (HWLs) are evidence-based tobacco control strategies; however, their application to e-cigarettes and related impacts (e.g. on perceived risk), including across countries with different regulations, are understudied. Design and Methods: Using 2021 survey data from 927 US and Israeli adults reporting past-month tobacco use, multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of e-cigarette HWLs (i.e. more concerned about e-cigarette use, reassured, no effect) among those who noticed e-cigarette HWLs (multinomial regressions); and (2) HWL impacts in relation to use intentions and perceived addictiveness and harm (linear regressions). Results: Among those who noticed HWLs (n = 835, 90.1%), 34.1% reported HWLs resulted in greater concern about e-cigarette use, 45.5% no effect, and 20.4% reassurance. Factors associated with greater concern (vs no effect) included e-cigarette non-use (vs use; aOR = 1.69, 95% CI:1.22, 2.38), US (vs Israel) resident (aOR = 1.65, 95% CI:1.16, 2.34), age 18-25 (vs 36-45; aOR = 1.72, 95% CI:1.11, 2.67), and more education (aOR = 1.85, 95% CI:1.30, 2.63). Factors associated with being reassured (vs no effect) included use of cigarettes (aOR = 1.71, 95% CI:1.06, 2.75), e-cigarettes (aOR = 2.64, 95% CI:1.77, 3.94), and other tobacco (aOR = 2.11, 95% CI:1.39, 3.21), and Israeli resident (aOR = 2.33, 95% CI:1.47, 3.70). Not noticing HWLs (vs no effect) correlated with lower intentions (ß = -0.44, 95% CI:-0.87, -0.01), perceived addictiveness (ß = -0.61, 95% CI:-1.05, -0.18), and harm (ß = -0.56, 95% CI:-0.95, -0.18); reassurance correlated with greater use intentions (ß = 0.48, 95% CI:0.12, 0.83); and greater concern was unassociated with use intentions or perceived risk. Conclusion: Effects of differing e-cigarette HWLs in distinct subpopulations warrant research. Despite being noticed, they may have no effect or encourage e-cigarette use.

Exposure to e-cigarette advertisements and non-advertising content in relation to use behaviors and perceptions among US and Israeli adults.

INTRODUCTION: As e-cigarette marketing strategies diversify, it is important to examine exposure to and impact of e-cigarette advertisements and non-advertising content (e.g. on social media) via multiple media channels among adults in different regulatory contexts. METHODS: Using 2021 cross-sectional data among 2222 adults in the US (n=1128) and Israel (n=1094), multivariable regression examined past-month e-cigarette advertisement and non-advertising content exposure in relation to past-month e-cigarette use (logistic regression), as well as use intentions and risk perceptions (linear regressions), controlling for sociodemographics and tobacco use. RESULTS: Overall, 20.3% reported past-month e-cigarette use (15.5% US, 25.2% Israel), 46.1% any advertisement exposure (28.7% digital media, 25.2% traditional media, 16.8% retail settings), and 34.1% any non-advertising exposure (19.4% social media, 13.6% websites, 12.3% movie/television/theater, 5.8% radio/podcasts). Exposure to digital media advertisements (AOR=1.95; 95% CI: 1.42-2.66), traditional media advertisements (AOR=2.00; 95% CI=1.49-2.68), and social media non-advertising (AOR=1.72; 95% CI: 1.25-2.36) correlated with e-cigarette use. Exposure to traditional media advertisements (ß=0.23; 95% CI: 0.08-0.38) and social media non-advertising (ß=0.26; 95% CI: 0.09-0.43) correlated with use intentions. Exposure to digital media advertisements (ß= -0.32; 95% CI: -0.57 - -0.08), retail setting advertisements (ß= -0.30; 95% CI: -0.58 - -0.03), and radio/podcast non-advertising (ß= -0.44; 95% CI: -0.84 - -0.03) correlated with lower perceived addictiveness. Radio/podcast non-advertising exposure (ß= -0.50; 95% CI: -0.84 - -0.16) correlated with lower perceived harm. However, retail setting advertisement exposure was associated with e-cigarette non-use (AOR=0.61; 95% CI: 0.42-0.87), and traditional media advertisement (ß=0.38; 95% CI: 0.15-0.61) and social media non-advertising exposure (ß=0.40; 95% CI: 0.14-0.66) correlated with greater perceived addictiveness. CONCLUSIONS: E-cigarette-related promotional content exposure across media platforms impacts perceptions and use, thus warranting regulation.

Profiles of tobacco product use and related consumer characteristics in the US and Israel: A multiple-group latent class analysis.

Despite tobacco marketing diversification, limited research has examined use profiles across countries, particularly in relation to consumer values (e.g. appeal of innovation, conscientiousness). Using 2021 data, latent class analysis assessed past-month use of seven tobacco products (cigarettes, electronic cigarettes [e-cigarettes], heated tobacco products, cigars, hookah, pipe, smokeless) among adults reporting past-month use in the United States (US n = 382) and Israel (n = 561). Multivariable multinomial regression examined consumer values and sociodemographics in relation to country-specific class membership. US classes included: primarily cigarette 58.1%; e-cigarette-no cigarette 17.5%; primarily cigar 14.9%; and poly-product 9.9%. Higher innovation correlated with e-cigarette-no cigarette and poly-product (vs. primarily cigarette) use. Other correlates included being: younger with e-cigarette-no cigarette; male, Black, and more educated with primarily cigar; and Black and Asian (vs. White) with poly-product. Israel classes included: primarily cigarette 39.0%; moderate poly-product 40.3%; high poly-product 13.4%; and hookah 7.3%. Lower conscientiousness correlated with moderate poly-product (vs. primarily cigarette) use; higher innovation correlated with high poly-product; lower innovation correlated with hookah. Other correlates included being: younger, male, and more educated with moderate poly-product; male and sexual minority with high poly-product; and Arab with hookah. Tobacco consumer segments within and across countries likely reflect different consumer values and industry marketing targets.

Theory-based correlates of cannabis use and intentions among US and Israeli adults: a mixed methods study.

BACKGROUND: In the US and Israel, non-medical ('recreational') cannabis use is illegal at the national level; however, use rates are high and decriminalization and legalization is spreading. Thus, theory-based intervention efforts, especially for youth prevention, are crucial. METHODS: This mixed-methods study of adults in the US (n = 1,128) and Israel (n = 1,094) analyzed: 1) cross-sectional survey data (Fall 2021) to identify theory-based correlates (risk perceptions, social norms) of past-month cannabis use, next-year use intentions, and intentions to use in the home or among children if non-medical cannabis was legal, using multivariable regression; and 2) qualitative interviews regarding perceptions of cannabis policies and use (US n = 40, Israel n = 44). RESULTS: 16.7% reported past-month use; 70.5%, 56.3%, and 82.6% indicated "not at all likely" regarding next-year use and use in the home and among children if legal. Lower perceived risk and greater social norms were associated with past-month use, greater use intentions, and greater intentions to use in the home or among children. Past-month use was more prevalent among US (vs. Israeli) participants (22.0% vs. 11.2%); however, in multivariable regression controlling for past-month use, being from Israel was associated with greater use intentions (next-year; in the home/among children). Qualitative themes indicated: concerns about use (e.g., increasing use, health risks, driving-related risks) and legalization (e.g., impact on society/economy, marketing), and perceived benefits of use (e.g., medical) and legalization (e.g., access/safety, economic, individual rights). CONCLUSIONS: Despite differences in cannabis perceptions and use across countries, perceived risk and social norms are relevant intervention targets regardless of sociopolitical context.

IQOS Marketing Strategies and Expenditures in the United States From Market Entrance in 2019 to Withdrawal in 2021.

INTRODUCTION: IQOS entered the U.S. market in October 2019, then received the Food and Drug Administration (FDA)'s modified risk tobacco product authorization (MRTPA) allowing use of "reduced exposure" claims in marketing in July 2020. A May 2021 court decision regarding patent infringement required IQOS' removal from the U.S. market in November 2021. AIMS AND METHODS: Using 2019-2021 Numerator marketing data, this study characterized ad occurrences and expenditures-including allocation per ad content (headline theme, imagery) and media type and channel-pre- and post-MRTPA; exploratory analyses characterized the post-court to withdrawal period separately. RESULTS: The study period entailed 685 occurrences and $15 451 870 in expenditures. The proportions of occurrences across the three periods (pre-MRTPA, post-MRTPA, and post-court) were 39.3%, 48.8%, and 12.0%, respectively (p < .001); the proportions of expenditures were 8.6%, 30.0%, and 61.5%. Overall, 73.1% of ad occurrences were via online display; 99.6% of expenditures occurred in print. Per occurrences, prominent pre-MRTPA headline themes included "future" (40.2%), "real tobacco" (38.7%), "get IQOS" (35.3%), and "innovation or technology" (20.1%); post-MRTPA, prominent themes included "not burned or heat control" (32.7%), "reduced exposure" (26.4%), and "distinct from e-cigarettes" (20.7%). Visuals mainly depicted the product alone (pre-MRTPA: 86.6%; post-MRTPA: 76.1%), but increasingly featured women (pre-MRTPA: 8.6%; post-MRTPA: 21.5%). The most prominent media channel theme pre-MRTPA was "technology" (19.7%), but post-MRTPA included "women's fashion" (20.4%) and "entertainment or pop culture/gaming" (19.0%). CONCLUSIONS: IQOS leveraged MRTPA in ads, continued marketing post-court decision, and targeted key consumer groups (ie, women). Marketing surveillance of products granted MRTPA is needed, domestically and in other countries, to assess its use and impact. IMPLICATIONS: Philip Morris (PM) leveraged IQOS' MRTPA from the U.S. FDA, and continued marketing IQOS after its withdrawal from the U.S. market due to a patent-infringement-related court decision. Notably, IQOS marketing increasingly targeted key consumer groups (eg, women). Given IQOS' potential return to the United States, PM's use of FDA's MRTPA to promote IQOS as a risk reduction product in other countries, and FDA's MRTPA for other products, it is crucial to monitor products receiving MRTPA, their marketing, and their population impact, domestically and in other countries.

A review of social media platform policies that address cannabis promotion, marketing and sales.

BACKGROUND: Cannabis marketing exposure via social media may impact use in youth and young adults. Most states with recreational cannabis lack policies regarding social media-based marketing. Thus, we examined such policies among prominent platforms, particularly those popular among youth and young adults. METHODS: In September-October 2022, 3 research team members extracted policies applying to the general community, advertising, and any specific content regarding drug-related content for 11 social media sites: Discord, Facebook, Instagram, Pinterest, Reddit, Snapchat, TikTok, Tumblr, Twitch, Twitter, and YouTube. Using inductive thematic analysis, they then dual-coded restrictions on cannabis-related content (e.g., paid advertising, unpaid promotion, sales). Descriptive analyses were conducted. RESULTS: Ten (all except TikTok) referenced cannabis/marijuana, 7 (all except Discord, Instagram, TikTok, and YouTube) distinguished different cannabis-derived products, and 5 (Reddit, Snapchat, TikTok, Tumblr, Twitter) noted jurisdictional differences in cannabis regulations/legality. All prohibited sales, 9 (all except Snapchat and Tumblr) prohibited paid advertising, and 4 (Discord, Reddit, Snapchat, TikTok) prohibited unpaid promotion (e.g., user-generated content). All restricted underage access to cannabis-related content. However, policies varied and were ambiguous regarding how "promotion" was defined, whether/how jurisdictional differences in legality were addressed, how businesses may interact on social media, barriers implemented to inhibit the facilitation of sales, and enforcement protocols. CONCLUSIONS: Social media policies regarding cannabis marketing are ambiguous and may facilitate cannabis marketing, promotion, sales, and underage exposure, thus compounding concerns regarding insufficient governmental regulations. Greater specificity in social media cannabis-related policies and enforcement is needed.

Cannabis retailer marketing strategies and regulatory compliance: A surveillance study of retailers in 5 US cities.

As cannabis retail expands in the US, its surveillance is crucial to inform regulations and protect consumers. This study addresses this need by conducting point-of-sale audits examining regulatory compliance (e.g., age verification, signage), advertising/promotional strategies, products, and pricing among 150 randomly-selected cannabis retailers in 5 US cities (30/city: Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California) in Summer 2022. Descriptive and bivariate analyses characterized the retailers overall and across cities. Age verification rates were high (>90%). The majority of retailers had signage indicating restricted access (e.g., no minors; 87.3%), onsite consumption (73.3%), and distribution to minors (53.3%). Retailers were likely to post warnings regarding use during pregnancy/breastfeeding (72.0%), followed by health risks (38.0%), impacts on children/youth (18.7%), and DUI (14.0%). Overall, 28.7% posted health claims, 20.7% posted youth-oriented signage, and 18.0% had youth-oriented packaging. Price promotions were prevalent, particularly price specials (75.3%), daily/weekly/monthly specials (66.7%), and membership programs (39.3%). One-fourth had signs/promotions indicating curbside delivery/pick-up (28.0%) and/or online ordering (25.3%); 64.7% promoted their website or social media page. The most potent cannabis products were most often e-liquids (38.0%) or oils (24.7%); the least potent were often edibles (53.0%). The most expensive product was often bud/flower (58.0%); the least was joints (54.0%). The vast majority (≥81%) sold vaporizers, wrapping papers, and hookah/waterpipes/bongs, and 22.6% sold CBD products. Marketing strategies differed across cities, reflecting differences in state-specific regulations and/or gaps in compliance/enforcement. Findings underscore the need for ongoing cannabis retail surveillance to inform future regulatory and enforcement efforts.