Social media use, brand engagement, and tobacco product initiation among youth: Evidence from a prospective cohort study.

OBJECTIVE: To evaluate whether frequent social media use and liking/following tobacco brand accounts was associated with increased risk of tobacco and polytobacco initiation over approximately 1-year follow-up among youth with no prior tobacco use. METHODS: Associations between measures of social media engagement (daily social media use and liking/following tobacco brands) and tobacco initiation risk were examined using data from Waves 2 and 3 (2014-2015) of the US Population Assessment for Tobacco and Health study. Separate log-binomial models, accounting for missing data via multiple imputation and using propensity score adjustment to address confounding, estimated the adjusted relative risk (aRR) of any tobacco initiation and poly-use (2 + products) initiation at 1-year follow-up. RESULTS: Among the 8,672 youth with no prior tobacco use (49.3% female, mean [SD] age 14.1 [1.7]), 63.5% used social media at least daily, and 3.3% reported liking/following ≥ 1 tobacco brands on social media. Those reporting daily or more frequent social media use (compared to less) were at increased risk for tobacco (aRR 1.67; 95% CI 1.38-2.02) and polytobacco initiation (aRR 1.32; 95% CI 0.98-1.78). Although results were imprecise, liking/following ≥ 1 tobacco brands on social media (versus none) was associated with tobacco (aRR 1.34; 95% CI 0.95-1.89) or polytobacco initiation (aRR 1.60; 95% CI 0.99-2.60). In sensitivity analyses, liking/following cigarette or cigarillo brands was associated with polytobacco initiation. CONCLUSIONS: This study adds to a growing evidence-base describing the exposure of youth to tobacco-related social media content. Such content-often generated by tobacco companies-may contribute to youth tobacco initiation.

Compliance With the US Food and Drug Administration's Guidelines for Health Warning Labels and Engagement in Little Cigar and Cigarillo Content: Computer Vision Analysis of Instagram Posts.

Background: Health warnings in tobacco advertisements provide health information while also increasing the perceived risks of tobacco use. However, existing federal laws requiring warnings on advertisements for tobacco products do not specify whether the rules apply to social media promotions. Objective: This study aims to examine the current state of influencer promotions of little cigars and cigarillos (LCCs) on Instagram and the use of health warnings in influencer promotions. Methods: Instagram influencers were identified as those who were tagged by any of the 3 leading LCC brand Instagram pages between 2018 and 2021. Posts from identified influencers, which mentioned one of the three brands were considered LCC influencer promotions. A novel Warning Label Multi-Layer Image Identification computer vision algorithm was developed to measure the presence and properties of health warnings in a sample of 889 influencer posts. Negative binomial regressions were performed to examine the associations of health warning properties with post engagement (number of likes and comments). Results: The Warning Label Multi-Layer Image Identification algorithm was 99.3% accurate in detecting the presence of health warnings. Only 8.2% (n=73) of LCC influencer posts included a health warning. Influencer posts that contained health warnings received fewer likes (incidence rate ratio 0.59, P<.001, 95% CI 0.48-0.71) and fewer comments (incidence rate ratio 0.46, P<.001, 95% CI 0.31-0.67). Conclusions: Health warnings are rarely used by influencers tagged by LCC brands' Instagram accounts. Very few influencer posts met the US Food and Drug Administration's health warning requirement of size and placement for tobacco advertising. The presence of a health warning was associated with lower social media engagement. Our study provides support for the implementation of comparable health warning requirements to social media tobacco promotions. Using an innovative computer vision approach to detect health warning labels in influencer promotions on social media is a novel strategy for monitoring health warning compliance in social media tobacco promotions.

Moralization of E-cigarette Use and Regulation: A Mixed-Method Computational Analysis of Opinion Polarization.

E-cigarette use, or vaping, is undergoing a process of moralization in which issues about vaping evolve from being morally neutral to having discernible moral implications. Using Moral Foundations Theory, this study compared the moral narratives underlying polarized views about e-cigarette use and regulation. We integrated computational and human strategies by conducting the Chow test on the time series data and classification, topic modeling, and Chi-square tests on posts (N = 2,669) from 26 pro-vaping and 19 anti-vaping Facebook Pages. The observation period (August 1, 2019 to March 5, 2020) encompassed the outbreak of "e-cigarette or vaping product use associated lung injury" (EVALI), deaths and subsequent legislation. Results revealed that pro-vaping posts were more likely than anti-vaping posts to mention Fairness/cheating and Authority/subversion, involving a conspiracy belief in an "e-cigarettes vs. Big Tobacco" rivalry, while anti-vaping posts were more likely to mention Sanctity/degradation. There were no significant differences between pro-vaping and anti-vaping posts in the likelihood of mentioning Care/harm or Loyalty/betrayal. Nevertheless, according to the topic modeling results, the use of moral foundations varied between pro-vaping and anti-vaping narratives, with the meanings of Care/harm and Loyalty/betrayal dependent on the post author's group affiliation. Health interventions can tailor persuasive messages to different moral values and debunk misinformation about public health policies to mitigate the vaping epidemic. Theoretical implications are also discussed.

The Impact of Influencers on Cigar Promotions: A Content Analysis of Large Cigar and Swisher Sweets Videos on TikTok.

Little is known about the content, promotions, and individuals in cigar-related videos on TikTok. TikTok videos with large cigar and Swisher Sweets-related hashtags between July 2016 and September 2020 were analyzed. Follower count was used to identify influencers. We compared content characteristics and demographics of featured individuals between cigar types, and by influencer status. We also examined the association between content characteristics and video engagement. Compared to large cigar videos, Swisher Sweets videos were more likely to feature arts and crafts with cigar packages, cannabis use, and flavored products. In addition, Swisher Sweets videos were also more likely to feature females, Black individuals, and younger individuals. Both Swisher Sweets and large cigar influencers posted more videos of cigar purchasing behaviors than non-influencers, which was associated with more video views. None of the videos disclosed sponsorship with #ad or #sponsored. Videos containing the use of cigar packages for arts and crafts, and flavored products highlight the importance of colorful packaging and flavors in the appeal of Swisher Sweets cigars, lending support for plain packaging requirements and the prohibition of flavors in cigar products to decrease the appeal of cigars. The presence and broad reach of cigar promotions on TikTok requires stricter enforcement of anti-tobacco promotion policies.

Predictors of COVID-19 Preventive Perceptions and Behaviors Among Millennials: Two Cross-sectional Survey Studies.

BACKGROUND: COVID-19 preventive perceptions and behaviors, especially among US millennials, are an important means by which the pandemic can be slowed and negative health outcomes can be averted. OBJECTIVE: This manuscript aims to advance knowledge on COVID-19 preventive perceptions and behaviors and their main predictors, including digital health information-seeking behavior (HISB), political party identification, and COVID-19 testing status. METHODS: Two cross-sectional online surveys of US millennials were conducted from April 10 to 14, 2020 (N=274) (ie, Study 1), and from April 27 to May 7, 2020 (N=1037) (ie, Study 2). In the regression models, dependent variables included preventive behaviors (eg, wearing a face mask and social distancing) as well as four preventive perceptions: severity (ie, a person's conception of the seriousness of COVID-19), susceptibility (ie, a person's conception of the likelihood of being infected with COVID-19), self-efficacy (ie, a person's perception that he or she can wear a face mask and perform social distancing to prevent COVID-19 infection), and response efficacy (ie, a person's perception of whether wearing a face mask and social distancing can prevent COVID-19 infection). Key independent variables included digital HISB for self, digital HISB for another person, political party identification, and COVID-19 testing status. RESULTS: Millennials reported lower levels of perceived susceptibility than the other three preventive perceptions (ie, severity, self-efficacy, and response efficacy), as well as fairly high levels of preventive behaviors. Unlike HISB for another person, digital HISB for self was positively associated with preventive perceptions and behaviors. In Study 1, respondents with higher levels of digital HISB for self had significantly higher perceptions of severity (ß=.22, P<.001), self-efficacy (ß=.15, P=.02), and response efficacy (ß=.25, P<.001) as well as, at nearing significance, higher perceptions of susceptibility (ß=.11, P=.07). In Study 2, respondents with higher levels of digital HISB for self had significantly higher perceptions of severity (ß=.25, P<.001), susceptibility (ß=.14, P<.001), and preventive behaviors (ß=.24, P<.001). Preventive behaviors did not vary significantly according to political party identification, but preventive perceptions did. In Study 1, respondents who identified as being more Republican had significantly lower perceptions of self-efficacy (ß=-.14, P=.02) and response efficacy (ß=-.13, P=.03) and, at nearing significance, lower perceptions of severity (ß=-.10, P=.08) and susceptibility (ß=-.12, P=.06). In Study 2, respondents who identified as being more Republican had significantly lower perceptions of severity (ß=-.08, P=.009). There were mixed effects of COVID-19 testing status on preventive perceptions, with respondents who had tested positive for COVID-19 having significantly higher perceptions of susceptibility in Study 1 (ß=.17, P=.006) and significantly lower perceptions of severity in Study 2 (ß=-.012, P<.001). CONCLUSIONS: As the largest and most digitally savvy generation, US millennials saw COVID-19 as a severe threat, but one that they were less susceptible to. For millennials, digital HISB for self, but not for another person, was critical to the development of preventive perceptions and behaviors.

JUUL the heartbreaker: Twitter analysis of cardiovascular health perceptions of vaping.

INTRODUCTION: The public most frequently associates tobacco use solely with pulmonary health risks, despite heart disease being the leading cause of death in smokers. The health perceptions of e-cigarettes, especially cardiovascular health, have not been well studied. We aimed to evaluate the prevalence and health perceptions of tweets related to cardiovascular, pulmonary, and brain health - three organ systems for which tobacco use is a major disease risk factor. METHODS: We examined the cardiovascular, pulmonary, and brain health perceptions of vaping and JUUL on Twitter, followed by a content analysis of tweets pertaining to the cardiovascular risks. A Twitter firehose API scraped about 6.2 million publicly available tweets from 2015-2019 that contained vaping-related terms, and a separate dataset of about 1.9 million tweets that contained the term JUUL. A quantitative content analysis (n=2145) of tweets was subsequently conducted to assess the health perceptions of vaping and JUUL. Two trained coders independently assessed the posts and Twitter profiles to determine age (<18 or ≥18 years), sex, race, sentiment towards JUUL, and vaping-related topics. RESULTS: The majority of tweets containing vaping or JUUL-related terms did not also contain cardiovascular, pulmonary, or brain health terms (97.99% and 96.67%, respectively). Multiple linear regression analysis showed that youth (<18 years), females, non-White individuals, mention of a flavor, and mention of cardiovascular health harm words were associated with more positive sentiments towards JUUL. Pearson's chi-squared analyses indicated that youth were more likely to mention a JUUL flavor. Females and youth were more likely to reference cardiovascular terms with humor. CONCLUSIONS: The cardiovascular health risks of vaping are not fully recognized by the public. Vulnerable populations such as youth and females reference JUUL with cardiovascular-related words that downplay the severity of tobacco as a major risk factor for cardiovascular disease.

Emotions in the time of coronavirus: Antecedents of digital and social media use among Millennials.

Increasingly, people are turning to digital and social media to address health threats. While research has commonly investigated the psychosocial antecedents of digital health information seeking behavior (digital HISB) and social media use (SMU), there has been limited research on the independent effects of emotions and no research on the interactive effects of emotions. In the context of the coronavirus COVID-19 pandemic, this study investigates the affective, personal relevance, and socio-demographic antecedents of digital HISB and SMU, using data from an online survey of U.S. Millennials (N = 1037) in April-May 2020. Linear regression results show the effects of socio-demographic and personal relevance factors. For the independent effects of emotions, fear and sadness were associated with digital HISB; fear, joy, and disgust were associated with high-informational SMU; and joy and disgust were associated with low-informational SMU. Three interactive effects of discrete negative emotions suggest that an increase in one emotion can amplify the effect of another emotion on a measure of digital and social media use. In the fourth interaction of two negative emotions with strong biological regulatory processes, there is evidence that an increase in one emotion can diminish the effect of another emotion. Implications for theory and practice are discussed.

The Role of Enjoyment in a Serious Game for Binge Drinking Prevention: Pretest-Posttest Quasi-Experimental Study.

BACKGROUND: Although binge drinking peaks at age 21 to 25 years, there is limited research on the effects of serious games in this population, as well as on the process by which playing serious games impacts alcohol-related outcomes. Designed with both health behavioral theory and game theory, One Shot is an online serious game that aims to prevent binge drinking. OBJECTIVE: This study utilized a conceptual model for serious video game processes. Using One Shot, the model assessed the following process stages: (1) Alcohol Use Disorders Identification Test-Concise (AUDIT-C); (2) in-game factors of game time and risky alcohol decisions; (3) game enjoyment; and (4) postgame outcomes of intention to drink less and drinking refusal self-efficacy. METHODS: In a one-group pretest-posttest quasi-experimental design, a sample (N=550) of young adults (age 21-25 years) who reported recent binge drinking played the One Shot game. Intention to drink less and drinking refusal self-efficacy were measured at pregame and postgame, with their effects lagged in statistical analysis. Participants were presented with various scenarios in the game that pertained to risky alcohol decisions, which, along with game time, were unobtrusively recorded by the server. A structural equation model (SEM) was used to test the conceptual model, with assessments made to determine if enjoyment mediated the effects of game time and risky alcohol decisions on the 2 postgame alcohol-related outcomes. RESULTS: A well-fitting SEM demonstrated support for the multistep model, with AUDIT-C predicting risky alcohol decisions (ß=.30). Risky alcohol decisions (ß=-.22) and game time (ß=.18) predicted enjoyment, which, in turn, predicted intention to drink less (ß=.21) and drinking refusal self-efficacy (ß=.16). Enjoyment significantly (P<.001) mediated the effects of game time and risky alcohol decision on intention to drink less and drinking refusal self-efficacy. CONCLUSIONS: The results support a conceptual model in which staggered individual and in-game factors influence alcohol-related outcomes. Enjoyment is important for participants' intentions to drink less and beliefs that they can refuse alcohol.

A panel study of peer norms and adolescent alcohol consumption: developing strategies for communication interventions.

Given that alcohol consumption and binge drinking among adolescents in the United States remain prevalent, this study assesses changes in the influence of peer norms-and their interactions with time, gender, and ethnicity-on alcohol consumption. Panel survey interviews of adolescents (N = 1,607) were completed in 9th grade and then again in 12th grade with students from Louisiana. Fixed effects multiple regression assessed the relations between the changes in 2 types of peer norms (i.e., descriptive norms and injunctive norms) and 2 alcohol consumption measures: 30-day alcohol prevalence and binge drinking. Increases in 30-day alcohol prevalence and binge drinking were associated with only descriptive norms. The effects of both types of peer norms intensified over time, and the effects of descriptive norms varied according to gender and ethnicity. Specifically, the influence of descriptive norms was greater on boys than on girls and on Caucasians than on African Americans. Communication interventions that target adolescents in the context of alcohol consumption should consider the temporal variability of peer normative influence and how it varies by gender and ethnicity.

A longitudinal analysis of adolescent smoking: using smoking status to differentiate the influence of body weight measures.

BACKGROUND: Previous research has reported mixed results on the association between body weight measures (ie, perception of weight and weight loss goal) and cigarette smoking prevalence-and how these associations vary by sex and race. This longitudinal study assessed the relationship between these 2 body weight measures and smoking prevalence by smoking status (ie, nonsmoker, former smoker, smoker). METHODS: Panel data of adolescents (N = 1592) from Louisiana schools completed survey interviews in the 9th grade and again in the 12th grade. Three separate ordinary least squares (OLS) regression analyses were conducted based on respondents' smoking status in the 9th grade: nonsmoker, former smoker, and smoker. The dependent variable, smoking prevalence was assessed in the 12th grade. RESULTS: Among nonsmokers, weight loss goal was associated with smoking in the 12th grade. Among former smokers, the association between weight loss goal and smoking varied by sex. Girls who reported the goal to lose weight smoked more than their male counterparts. In contrast, among those who did not have the goal of losing weight, boys smoked more than girls. Among adolescents who were already smokers in the 9th grade, weight loss goal was not significantly associated with smoking prevalence. CONCLUSION: Differences in the association between weight-related variables and smoking prevalence may be attributed, in part, to smoking status. School-based smoking interventions should target nonsmokers and female former smokers who desire weight loss.

Media use and perceived risk as predictors of marijuana use.

OBJECTIVES: To assess the influence of media use and perceived risk on marijuana use outcomes. METHODS: With survey data from 750 US young adults, structural equation modeling tested how attitudes, behaviors, and behavioral intention specific to marijuana use are influenced by perceived personal and societal risk of marijuana use, media campaign exposure, and news use. RESULTS: Perceived societal risk had significant effects, though not as strong as perceived personal risk. Campaign exposure had favorable effects whereas those of news use were mixed. CONCLUSIONS: Perceived personal risk and perceived societal risk should be considered when designing preventive media campaigns.

Health information seeking, diet and physical activity: an empirical assessment by medium and critical demographics.

PURPOSE: Research over the past decade has conveyed a dramatic rise in health information seeking via the Internet and articulated various profiles and outcomes of health information seeking. In building upon this research, the current study is innovative in considering predictors of health information seeking by medium, as well as outcomes of health information seeking by medium and by critical demographics. METHODS: OLS regression and logistic regression are conducted on data from a telephone survey of American adults in 2007 (N=700). RESULTS: Profiles of health information seekers vary dramatically by medium (Internet versus newspapers versus television). In terms of outcomes, newspaper health information seeking is associated with fruit and vegetable consumption, while television health information seeking is associated with sweetened soft drink consumption. There are four significant interaction terms between these two health information seeking variables and unhealthy snack consumption. Internet health information seeking has no significant effects. CONCLUSIONS: In comparison to the Internet, newspaper and television media have more favorable associations with recommended levels of lifestyle behaviors that may be critical in efforts to decrease obesity in the United States.

Social environmental and individual factors associated with smoking among a panel of adolescent girls.

This study assessed changes in the influence of social environmental and individual factors-and the interaction of these factors with time-on smoking prevalence for girls. Longitudinal panel surveys of adolescent girls (N = 921 in both 2000 and 2004) from schools in Louisiana were completed in the ninth grade (2000) and then again in the twelfth grade (2004). A fixed effects hierarchical multiple regression model assessed the relation of changes in social environmental and individual factors to smoking prevalence. Increases in smoking prevalence over time among adolescent girls were associated with their perceptions of themselves as overweight and perceiving low risk associated with smoking. Increases in smoking prevalence over time were also associated with having friends who smoked, perceptions of friends' approval of smoking, having family members who smoked, and having monetary discretionary spending. Having friends who smoked was more strongly associated with smoking in the twelfth grade than in the ninth grade. While more black adolescent girls smoked than did white girls in the ninth grade, by the twelfth grade, more white adolescents girls smoked than did black girls. Interventions that target adolescent girls should consider the temporal variability of individual and social environmental factors.

Internet health information in the patient-provider dialogue.

A patient discussing Internet health information with a health care provider (referred to as "patient-provider communication about Internet health information") can contribute positively to health outcomes. Although research has found that once Internet access is achieved, there are no ethnic differences in Internet health information seeking, it is unclear if there are ethnic differences in patient-provider communication about Internet health information. To help fill this gap in the literature, the National Cancer Institute's Health Information National Trends Survey 2005 was analyzed with Stata 9. Two sets of logistic regression analyses were conducted, one for a subsample of Internet users (n = 3,244) and one for a subsample of Internet users who are first-generation immigrants (n = 563). The dependent variable was patient-provider communication about Internet health information, which assessed whether survey participants had discussed online health information with a health care provider. The predictor variables included trust of health care provider, trust of online health information, Internet use, health care coverage, frequency of visits to health care provider, health status, and demographics. Among all Internet users, Whites had higher levels of patient-provider communication about Internet health information than Blacks and Asians. Similarly, among Internet users who are immigrants, Whites had higher levels of patient-provider communication about Internet health information than Blacks and Asians. While the digital divide is narrowing in terms of Internet access, racial differences in patient-provider communication about Internet health information may undermine the potential benefits of the information age.

Urban residents' priorities for neighborhood features. A survey of New Orleans residents after Hurricane Katrina.

BACKGROUND: Efforts to promote physical activity through environmental changes in low-income, urban, and minority areas should be informed by an understanding of the value that residents place on different neighborhood features and characteristics. METHODS: Neighborhood rebuilding preferences among 442 New Orleans residents after the damage from Hurricane Katrina were assessed by a random-digit-dialed telephone survey conducted between April 25, 2006 and May 2, 2006. The survey instrument assessed the importance (on a 5-point Likert-type scale on which 1=not at all important and 5=extremely important) for 24 neighborhood features and characteristics. Ratings of neighborhood features were compared by race and income. RESULTS: Overall, residents rated most highly the features that reflected low levels of neighborhood crime and disorder. There was moderate support for features that promote physical activity, specifically sidewalks and crosswalks, neighborhood grocery stores, and parks or playgrounds. Blacks rated more highly than whites 13 neighborhood features such as good schools, lack of noise, a park or playground, affordable housing, health clinics, and the absence of liquor stores. The low-income group rated the following features as being more important than the high-income group: affordable housing, a bus or streetcar line, and the presence of a corner store. CONCLUSIONS: New Orleans residents' top neighborhood priority is reducing crime and disorder, but all groups otherwise support neighborhood features that promote physical activity.

Process evaluation of an in-school anti-tobacco media campaign in Louisiana.

OBJECTIVES: In light of challenges imposed by the changing media landscape and decreasing classroom time available for health interventions, new approaches are needed to disseminate anti-tobacco messages to adolescents. This study reported process evaluation of an in-school three-year anti-tobacco media campaign conducted in 10 schools in Louisiana. METHODS: Over three years, 10 schools received an in-school anti-tobacco media campaign. The media campaign was one intervention component of the Acadiana Coalition of Teens against Tobacco. Campaign measures were tracked over the campaign's three-year duration. The campaign and evaluation were designed to target the students as they progressed through high school. The number of students who completed the surveys were 1,823 in Year 1, 1,552 in Year 2, and 1,390 in Year 3. Schools eligible for participation were publicly funded schools with no magnet or special populations and within a two-hour driving distance of the New Orleans study office. RESULTS: In a self-report survey (Year 1, n = 1,823; Year 2, n = 1,552; Year 3, n = 1,390), more than 75% and 50% of students reported being exposed to posters and public service announcements, respectively. Recognition of campaign theme was more than 80%. Almost half of respondents reported that the posters were interesting, one-third reported that the posters prevented them from smoking, and 10% reported that the posters encouraged them to cease smoking. Stock media posters had a significantly higher affective reaction than the customized media posters. CONCLUSION: Findings suggest that in-school media programs are useful and should be considered as a viable approach to health education for adolescents.

Information control in time of crisis: the framing of SARS in China-based newspapers and Internet sources.

A content analysis examined 727 SARS news stories from a commercial China-based Web portal, a national Chinese newspaper, and a Chinese regional newspaper. Coding included news frames (health severity, human interest, economic, attribution of responsibility, denial) and the type of cited sources (domestic and international). MANOVA analyses indicated that the national newspaper used the health severity frame more often than the regional newspaper. The China-based Web portal used the economic frame and international sources significantly more often than either newspaper. Results are discussed in terms of the future of the Internet in China as a tool to mitigate the spread of infectious diseases through rapid information dissemination.

Promoting youth health by social empowerment: a media campaign targeting social capital.

This article reports on a public health campaign that aims to promote social ties and social trust as a means to improve the health of youths. Analyses on data from telephone survey interviews at baseline, Year 1, and Year 2 consider the trends and predictor patterns of 2 traditional social capital measures-civic perceptions and civic participation. Civic perceptions increased over the course of the focal media campaign, whereas civic participation remained constant. Civic participation was positively associated with TV and newspaper campaign recall at Year 1, whereas both civic participation and civic perceptions were positively associated with TV and newspaper campaign recall at Year 2. In addition, newspaper and TV news use play positive roles in predicting the 2 social capital measures at Year 1 and Year 2. The findings are discussed in terms of literature in the areas of public health and mass communication.

Contributing factors to the use of health-related websites.

This study explicates the influence of audience factors on website credibility and the subsequent effect that credibility has on the intention to revisit a site. It does so in an experimental setting in which participants were given two health-related search tasks. Reliance on the web for health-related information positively influenced website credibility in both searches. Knowledge was a significant predictor for the search task that required more cognitive ability. Of the credibility dimensions, trust/expertise and depth were significant predictors of intention to revisit a site in both searches. Fairness and goodwill were nonsignificant predictors in both searches.

Presence of pro-tobacco messages on the Web.

Ignored in the finalized Master Settlement Agreement (National Association of Attorneys General, 1998), the unmonitored, unregulated World Wide Web (Web) can operate as a major vehicle for delivering pro-tobacco messages, images, and products to millions of young consumers. A content analysis of 318 randomly sampled pro-tobacco Web sites revealed that tobacco has a pervasive presence on the Web, especially on e-commerce sites and sites featuring hobbies, recreation, and "fetishes." Products can be ordered online on nearly 50% of the sites, but only 23% of the sites included underage verification. Further, only 11% of these sites contain health warnings. Instead, pro-tobacco sites frequently associate smoking with "glamorous" and "alternative" lifestyles, and with images of young males and young (thin, attractive) females. Finally, many of the Web sites offered interactive site features that are potentially appealing to young Web users. Recommendations for future research and counterstrategies are discussed.