Warning Labels as a Public Health Intervention: Effects and Challenges for Tobacco, Cannabis, and Opioid Medications.

Warning labels help consumers understand product risks, enabling informed decisions. Since the 1966 introduction of cigarette warning labels in the United States, research has determined the most effective message content (health effects information) and format (brand-free packaging with pictures). However, new challenges have emerged. This article reviews the current state of tobacco warning labels in the United States, where legal battles have stalled pictorial cigarette warnings and new products such as electronic cigarettes and synthetic nicotine products pose unknown health risks. This article describes the emerging research on cannabis warnings; as more places legalize recreational cannabis, they are adopting lessons from tobacco warnings. However, its uncertain legal status and widespread underestimation of harms impede strict warning standards. The article also reviews opioid medication warning labels, suggesting that lessons from tobacco could help in the development of effective and culturally appropriate FDA-compliant opioid warning labels that promote safe medication use and increased co-dispensing of naloxone. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

A systematic review of cannabis health warning research.

Background: Cannabis legalization provides an opportunity to communicate with consumers through mandated health warnings on cannabis packaging. However, research on cannabis health warnings is a nascent field. Therefore, a review is needed to synthesize cannabis health warning research and inform ongoing policy discussions. Methods: This paper used systematic review guidelines to search online databases, including PubMed Central, Scopus, Web of Science, Jstor, Communication and Mass Media Complete, Medline, PsycINFO, and Google Scholar. Search strings combined the terms "cannabis" or "marijuana" with "health warning" or "health warning message" or "warning label" or "health warning label" or "health information label." Results were synthesized narratively. Results: The search identified 90 research articles. After screening, 17 studies on the impact of cannabis health warnings were retained. Retained studies focused on the hypothetical effects of cannabis health warnings (n = 11; 64.7 %) and "real world" effects of implementing warnings post-legalization (n = 6; 35.3 %). Evidence indicated mandated cannabis health warnings improved noticing and recall of health warning content. Cannabis health warnings describing risks of addiction were consistently rated the least effective. Pictorial cannabis health warnings generally outperformed text-only warnings when displayed on their own, while experiments with warnings on products had mixed results. Cannabis health warnings decreased product appeal, mainly when package branding was minimized. Conclusions: Health warnings on cannabis packaging are an important strategy to communicate risk to consumers. Mandating warnings increased notice, recall, and health knowledge. Warnings with pictures and describing specific risks were most effective, as was showing warnings without product branding.

Reactance, Mortality Salience, and Skin-Cancer Prevention Among Young Adults.

In an experiment (N = 206) using skin cancer prevention messages and a 2 (mortality: salient, control) × 2 (freedom-limiting language: freedom-limiting, autonomy-supportive) independent-group design, we tested the terror management health model and integrated its predictions with the theory of psychological reactance. We used a sample of young adults because they are most at risk for excessive tanning. Consistent with the study predictions about proximal defenses, mortality salience significantly increased intentions to wear sunscreen all year around, relative to the control condition. A significant interaction between freedom-limiting language and mortality salience on behavioral intention to purchase high-SPF lotion revealed that, when a freedom-limiting message was paired with mortality salience, intentions to purchase high-SPF lotion were significantly greater as compared to autonomy-supportive language, indicating that mortality salience mitigated the maladaptive effects of reactance. These results add to a growing body of research identifying boundary conditions for reactance effects and, further, point to the utility of directive (albeit freedom-limiting language) in health-prevention messages attempting to communicate deadly health risks.

It's addiction at this Point": A qualitative examination of youth E-cigarette use trajectory in the United States.

E-cigarettes (electronic cigarettes) have been the most used tobacco product among US youth since 2014, reaching a plateau during the COVID-19 pandemic. Youth e-cigarette use is associated with negative health consequences such as impaired cognitive functioning. For many, the COVID-19 pandemic altered social interactions, harm perceptions, and product availability. This changed the frequency and locations in which youth use e-cigarettes. To better understand youth e-cigarette use, we need more information on factors that can alter e-cigarette use, specifically, how the pandemic changed e-cigarette use among youth. In 2020-2021, we conducted online, individual interviews with 19 youth (aged 13-17) e-cigarette users living in the US to explore how COVID-19 impacted their e-cigarette use. Youth described a progression of e-cigarette use from initial experimentation, regular social use, and ultimately to nicotine addiction demonstrated by individual use in isolation. Many youth initiated e-cigarette use due to influences by friends or family members. Youth discussed progression to social use, with social interactions as an important reason for use and an avenue for expanding one's knowledge of e-cigarettes. After a period of time, youth began to recognize that the social interactions mattered less, suggesting to them that they had become addicted. This realization became more apparent during COVID-19, which changed how youth used e-cigarettes, especially around where use was occurring, health concerns, and use behavior and frequency. In our interviews, youth trajectory began with an initiation with family and friends, progressed to social use, and eventually developed to addiction, at which point social use was no longer the primary motivation for e-cigarette use. Understanding the trajectory of e-cigarette use will allow for effective interventions that reduce harm to youth from e-cigarette use.

"I Get the Flavors and It Makes Me Love Vaping More": How and Why Youth Users Modify Electronic Nicotine Delivery Systems.

INTRODUCTION: Youth in the United States are using electronic nicotine delivery systems (ENDS) at a high rate. Modifications to ENDS by youth can introduce additional health hazards which have not been previously considered. To better understand these risks, we need more information on what these modifications are, the motivations behind them, and the sources of information on modifications. AIMS AND METHODS: Utilizing a trained moderator, in 2020-2021, we conducted one-on-one interviews with 19 youth ENDS users aged 16-17 living in the United States and analyzed their responses using a qualitative description approach. RESULTS: The most prominent modification was to the e-liquid; youth indicated they mixed e-juices to create new flavors and added substances not intended for vaping, including illicit drugs such as cannabis and cocaine. Few youths from our sample were interested in achieving a specific nicotine level to vape, and modifications to the battery, coil and wick were less frequently mentioned. Some of these modifications were motivated by a desire to achieve specific experiences with their device. At other times, modifications were made due to necessity because of limited access to ENDS devices and supplies. YouTube and peers were the main sources of information about modifying. CONCLUSIONS: Youth are making modifications that are both intended and unintended by the manufacturer. Adding illicit drugs and other substances not made for vaping is of particular concern. Understanding how youth modify ENDS and how that changes their use is important to guide regulatory policy intended to reduce harm to youth from ENDS use. IMPLICATIONS: Youth from our study indicated that they make modifications to the ENDS devices, specifically to the e-liquid. These modifications are both intended by the manufacturer, such as changing the e-liquid and replacing coils, and unintended, such as adding substances not meant for vaping. Future policies aimed at reducing youth ENDS use should consider mandating better safeguards against modifications that appeal to youth.

The effects of death awareness and reactance on texting-and-driving prevention.

Using a 2 (mortality: salient, control) × 2 (freedom-limiting language: freedom-limiting, autonomy-supportive) independent-group design, this study examined the relationship between mortality salience and psychological reactance in the context of texting-and-driving prevention messages. The terror management health model and the theory of psychological reactance guided study predictions. Results showed mortality salience produced adaptive effects on attitudes toward texting-and-driving prevention and behavioral intentions to reduce unsafe driving practices. Additionally, some evidence for the effectiveness of directive, albeit freedom-limiting communication, emerged. These and other results are discussed along with the implications, limitations, and future research directions.

When Cigarette Smoking Meets COVID-19: How the Two Types of Threat and Efficacy Perceptions Interactively Predict Danger Control and Fear Control Processes.

Growing evidence indicates that communicating the combined risk of smoking and COVID-19 encourages smoking cessation. Guided by the Extended Parallel Process Model (EPPM), we examined how perceived threats of smoking and COVID-19 independently and interactively predicted danger control responses (i.e., quit intentions and COVID-19-protective behavioral intentions) and fear control responses (i.e., fear and fatalism). We also explored the direct and interactive impacts of perceived efficacy of quitting smoking and COVID-protective behaviors on message outcomes. Structural equation modeling results (N = 747 U.S. adults who smoke) indicated that the perceived efficacy of COVID-protective behaviors positively predicted quit intentions. Higher perceived threat of COVID-19 and greater quitting efficacy predicted higher quit intentions directly and indirectly via fear. As perceived COVID-protective efficacy increased, the positive association between perceived quitting efficacy and quit intentions also increased. Smoking-related threat and efficacy perceptions did not predict COVID-protective behavioral intentions. This study added to EPPM by considering how threat and efficacy perceptions deriving from two different yet closely related risks affect protective behaviors. Thus, combining multiple threats in a single message might be a promising strategy to motivate smoking cessation amid the pandemic.

General and Device-Specific Reasons for ENDS Use: A Qualitative Study with Adult ENDS Users.

BACKGROUND: A scientific consensus on the public health impact of electronic nicotine delivery systems (ENDS) remains elusive. This is partly due to the wide variation in product characteristics often lumped together under one category. Research is needed to better understand what ENDS device type characteristics motivate their use by adults. METHODS: Nine focus groups of 32 current ENDS users who were 18+ years old, had used ENDS in the previous 30 days, and had been using ENDS for more than two months were held either in person or online between February and June 2020. RESULTS: Participants' reasons for their choice of ENDS characteristics included both general, applying to all ENDS products, and specific, relating to particular ENDS devices. Health benefits and the lack of offensive odor were commonly identified as important reasons for using ENDS in general. Flavor and product discreteness were both general and device-specific determinants of ENDS use. Conversely, nicotine delivery, cloud size, battery properties, aesthetics, ease of use, and cost were device-specific drivers of participants' choice. CONCLUSIONS: The reasons that adults choose to use ENDS are complex and sometimes related to both ENDS as a category and as specific ENDS product types. Regulations and public communication campaigns should reflect their ultimate objective and consider both general and specific motivations when attempting to achieve public health objectives.

Disparities among smokers during the COVID-19 pandemic: Examination of COVID-19-related worries by sociodemographic factors in a U.S. Nationally representative survey.

Low-socioeconomic status (SES) and certain racial/ethnic minority groups disproportionately experience tobacco-related disease and death. Underserved populations of smokers may be at disproportionate risk for elevated stress and worry related to basic needs and healthcare during the pandemic, which could impede smoking cessation and exacerbate health disparities. This study examined whether experiences with stress and worry among smokers during the COVID-19 pandemic differed by sociodemographic factors, and whether these factors predicted serious psychological distress (SPD). Data came from an October-November 2020 U.S. national representative survey of 1,223 current cigarette smokers. Analyses examined associations between sociodemographic factors with COVID-19-related worries and past-month SPD. Worry in most domains (e.g., food, housing, finances, healthcare) was more prevalent among participants with less than high school education, income less than $30,000, and those who were unemployed. Women and participants aged 30-44, with income less than $30,000, with less than high school education, not working/disabled, or on Medicaid were more likely to experience SPD. Examined separately, each COVID-19 worry predicted higher likelihood of SPD. In adjusted models, COVID-19 worries about finances (aOR = 2.3) and isolation/loneliness (aOR = 3.0) uniquely predicted SPD. Among U.S. adult smokers during the COVID-19 pandemic, those with lower SES indicated disproportionately high worry about access to basic needs and were more likely to experience SPD. Policies and interventions that address basic needs and mental health among marginalized populations of tobacco users are needed.

Examining reactions to smoking and COVID-19 risk messages: An experimental study with people who smoke.

BACKGROUND: Smoking cigarettes worsens COVID-19 outcomes, and news media and health agencies have been communicating about that. However, few studies have examined how these messages affect attitudes, beliefs, and behavioral intentions of people who smoke. These are critical variables that can inform public health campaigns to motivate quitting smoking during the COVID-19 crisis. METHODS: In August 2020, we conducted an online experiment in the U.S. with 1,004 adults who smoke. Participants were randomized to one of four message conditions: COVID-19 risk, smoking risk, combined risk of smoking for COVID-19 severity, or a non-risk control. Outcomes were message reactions (emotions and reactance), attitudes and beliefs (severity, susceptibility, self-efficacy, response efficacy for smoking and COVID-19, and conspiracy beliefs), and behavioral intentions (smoking intentions, COVID-protective intentions, and information-seeking). RESULTS: Multivariate analysis of covariance (MANCOVA) showed that combined risk messages elicited higher perceived severity of smoking-related disease than control messages. Similarly, the combined risk condition resulted in greater intentions to quit smoking in the next month (vs. COVID-19 risk condition) and intentions to reduce smoking in the next 6 months (vs. smoking risk and control; ps < .05). Multivariate logistic regression found that exposure to the combined risk messages (vs. control as referent) was associated with higher odds of mask-wearing intentions in the next 2 weeks (AOR = 1.97). CONCLUSIONS: Health agencies can possibly use messages that communicate about the combined risk of smoking and COVID-19 as a novel strategy to motivate people who smoke to quit and take protective action for COVID-19.

Effects of modified risk tobacco product claims on consumer comprehension and risk perceptions of IQOS.

INTRODUCTION: Tobacco industry studies on consumers' perceptions of modified risk claims (MRCs) often had important omissions (eg, no control group, not investigating whether consumers understand what 'switching completely' means). This study examined the effects of IQOS MRCs on risk perceptions and behavioural intentions. METHOD: Based on tobacco companies' MRCs, we manipulated three MRC language features: explanation about 'switching completely' (absent vs present), number of diseases (single vs multiple) and language certainty (hypothetical vs certain). In an online experiment, we randomised 1523 US adult current smokers and 1391 young adult non-smokers to 1 of 9 conditions following a 2×2×2+1 control design. People reported their comprehension of 'switching completely', IQOS risk perceptions and behavioural intentions after message exposure. RESULTS: More smokers exposed to MRCs that included an explanation about 'switching completely' (22.2%) (vs explanation absent (11.2%) and control (10.7%)) mentioned that 'switching completely' meant smoking 0 cigarettes. Compared with the control, several MRCs (eg, certain language) produced lower perceived risk of IQOS, including for diseases not mentioned in the MRCs. MRCs using certain and hypothetical language did not differ on any outcomes. MRCs highlighting reduced risk for a single disease and multiple diseases did not differ on any outcomes. MRCs did not influence behavioural intentions. CONCLUSION: The Food and Drug Administration should ensure that consumers understand what 'switching completely' means in an MRC and recognize that some language features may mislead consumers into believing that a product reduces the risk of diseases not mentioned in an MRC.

Serious Psychological Distress Is Associated with Higher Intentions to Quit among Smokers during the COVID-19 Pandemic.

COVID-19 has increased the rates of serious psychological distress (SPD) among the general population. However, the SPD among smokers during the pandemic remains understudied. In a parent study, 1,004 U.S. adult smokers with and without SPD were randomized to view messages about COVID-19 risk, smoking risk, combined COVID-19 and smoking risk, or control. Outcomes were smoking quit intentions and COVID-19 protective behavior intentions. We analyzed the prevalence of SPD among current smokers; the associations between SPD, personal characteristics, and smoking and COVID-19 protective behavioral intentions; and whether SPD moderated the effect of messages about risks of smoking and COVID-19.Thirty-six percent of smokers met the criteria for SPD. Odds of having SPD were higher for older, everyday smokers, who had COVID-19, had poor health and conservative ideology. Smokers with SPD were significantly more likely to report intentions to quit smoking and seek counseling than smokers without SPD, controlling for demographics, readiness to quit, and message condition. SPD was not significantly related to COVID-19 protective intentions. The interactions between SPD and messages were nonsignificant. During the pandemic, smokers with SPD may be motivated to quit smoking, which provides an opportunity for targeted interventions to increase quit attempts.

Are smokers scared by COVID-19 risk? How fear and comparative optimism influence smokers' intentions to take measures to quit smoking.

Research suggests that smoking may compound the risk of serious health problems to smokers who contract COVID-19. This study examines whether and how exposure to news stories reporting the severe COVID-19 risk to smokers may influence smokers' emotional responses (fear, anxiety, and sadness) and intentions to take measures to quit smoking. Current smokers in the US participated in an online experiment (N = 495) and were randomized to read smoking risk news stories or news stories reporting the combined risk of smoking and COVID-19. We found that combined risk news stories lead to participants feeling more fearful and sadder than when they viewed smoking risk news stories (M = 5.74; SD = 2.57 vs. M = 5.20; SD = 2.74; p < .05). Fear fully mediated the effect of news exposure on intentions to take measures to quit smoking (ß = .09; SE = 05; 95% CI [.010, .200]). Moreover, moderated-mediation analyses revealed that the mediating effect of fear was conditioned on the levels of comparative optimism, such that the association between fear and intentions to take measures to quit smoking was only significant among smokers whose comparative optimism was at the mean score (ß = .16; SE = 05; 95% CI [.071, .250]), and for those whose comparative optimism was high (ß = .27; SE = .06; 95% CI [.146, .395]). These results suggest that fear of the pandemic and optimism might play important roles in predicting and explaining the association between exposure to news stories and intentions to take measures to quit smoking. Messages about heightened risk of COVID-19 complications for smokers that increase fear might be an effective strategy to motivate smokers to quit. Such messages should be used to turn the adversity of COVID-19 pandemic into an intervention opportunity to reduce tobacco-related disease.

Associations between COVID-19 risk perceptions and smoking and quitting behavior among U.S. adults.

OBJECTIVES: The COVID-19 pandemic may impact cigarette smokers' behaviors. Among smokers, perceptions about the risks of contracting COVID-19 and the severity of COVID-19 illness likely vary, and perceptions may be associated with individual smoking behavior. Our study measured smokers' perceptions of COVID-19 risks and their association with smoking and quitting outcomes. METHODS: A sample of 1,223 U.S. adult cigarette smokers participated in an online survey in October-November 2020 to assess their COVID-19-related risk perceptions and changes in smoking, readiness to quit, and quit attempts during the COVID-19 pandemic. RESULTS: More smokers believed smoking could increase the severity of COVID-19 (43.6%, 95% CI: 40.1, 47.3) than believed smoking makes them more susceptible to COVID-19 (20.0%, 95% CI: 17.2, 23.0.). While there were no associations between perceptions of COVID-19 susceptibility and smoking behaviors or intentions, perceptions of greater smoking-related COVID-19 severity were associated with both higher likelihood of smoking increases (aOR: 2.16, 95% CI: 1.19, 3.93) and greater readiness to quit smoking (aOR: 1.65, 95% CI: 1.18, 2.30). Greater perceptions of general COVID-19 severity were associated with higher likelihood of smoking reductions (aOR: 1.12, 95% CI: 1.02, 1.22), greater readiness to quit smoking (aOR: 1.14, 95% CI: 1.07, 1.22), and higher likelihood of making a quit attempt (aOR: 1.12, 95% CI: 1.04, 1.22). CONCLUSIONS: Smokers' perceptions about COVID-19 severity are related to their smoking behavior and likelihood of making a quit attempt. Providing smokers with accurate information on the relationship between smoking and the severity of COVID-19 may alter smoking behaviors.

"It's Cool, Modifying and All, but I Don't Want Anything Blowing Up on Me:" A Focus Group Study of Motivations to Modify Electronic Nicotine Delivery Systems (ENDS).

INTRODUCTION: Modifications to electronic nicoti ne delivery systems (ENDS) can pose health risks to users. This study explored users' motivations for modifying ENDS devices and how perceived risks of modifications influenced modification behaviors as product availability and device characteristics changed over time. METHOD: We conducted nine focus groups (February-June 2020) with 32 current ENDS users (18+, used ENDS in the past 30 days, and had been using ENDS for more than 2 months). RESULTS: Participants primarily modified ENDS devices to improve their experiences, such as experimenting with flavor, controlling nicotine levels, or using cannabis products with ENDS. Another reason for modifying was routine maintenance to ensure a satisfactory experience, including maintaining coils and keeping batteries charged. The broader availability of ENDS products shifted modification behaviors over time, with newer devices making some modifications (e.g., coil replacement) easier and making more intricate modifications (e.g., building coil from scratch) less common. Participants were aware of modification dangers and cited perceived risk as the reason for avoiding certain modifications, such as battery alterations. CONCLUSIONS: Modifications of ENDS are ongoing and evolving among users and should be considered by the Food and Drug Administration (FDA) and other regulatory decision-makers as product authorization reviews are conducted and product standards are developed.

Dripping Technology Use Among Young Adult E-Cigarette Users.

BACKGROUND: Young adults are increasingly using electronic nicotine delivery systems (ENDS). The standard ENDS device involves an electric coil that heats a wick to vaporize an e-liquid solution. "Dripping" is another method that involves applying e-liquid directly to the coil. Dripping increases risk of harmful toxic compounds in vapor aerosols. Despite evidence of high levels of dripping among adolescents, young adult prevalence is unknown. METHODS: Young adults aged 18 to 24 completed an online survey assessing vaping and dripping status, type of devices used, tobacco use, and vaping expectancies. Among ever-vapers, univariate and multivariate logistic regression models assessed whether demographics predicted dripping and use of dripping devices. Multivariate Analysis of Variance compared never- and ever-drippers on expectancies for vaping outcomes. RESULTS: Over 2 in 5 young adult ever-vapers (43.7%) reported dripping. A multivariate regression model found that male gender (AOR = 1.83), identifying as White (AOR = 2.37), and use of other tobacco products (hookah; AOR = 1.91; cigars; AOR = 2.26; cigarettes; AOR = 2.51) were associated with dripping. E-cigarette users who reported lifetime dripping were more likely to consider vaping stimulating, socially facilitating, and flavorful. They ascribed lower health risks to vaping and felt it could reduce negative affect, weight gain, nicotine cravings, and boredom (all P < .05). CONCLUSION: Dripping was a highly prevalent behavior among this sample of young adults, particularly among White males. These findings point to the importance of gaining a greater understanding of the drivers and consequences of vaping and dripping behavior.

Vaping, smartphones, and social media use among young adults: Snapchat is the platform of choice for young adult vapers.

BACKGROUND: Tobacco use often begins or stabilizes in young adulthood. Approximately 90% of young adults use social media and over 80% own a smartphone. Retailers of electronic nicotine delivery systems (ENDS) have targeted smartphones and social media with adverting campaigns. Despite evidence of ENDS advertising on social media and smartphones, few studies have examined associations between exposure to vaping advertisements on smartphones, social media use, and ENDS use (i.e., vaping) among young adults. METHODS: College students aged 18-24 from a large public university (N = 1047) completed online surveys about vaping. The survey measured frequency of vaping advertisement exposure, smartphone use, social media use, and vaping behaviors. Hierarchical logistic regression assessed whether demographics, vaping advertisement exposure, smartphone use, and social media use predicted ever vaping compared to never vaping. RESULTS: The four most commonly used platforms (used "daily") were Snapchat (80.0%), Instagram (73.4%), YouTube (59.7%), and Facebook (54.3%). Use of Snapchat, Instagram, and Facebook were all significantly associated with higher rates of vaping advertisement exposure via smartphones. Exposure to vaping advertisements on smartphones was associated with ever vaping (AOR: 1.30, 95% CI = 1.05-1.60). Of the social media platforms examined, only Snapchat use frequency was associated with higher odds of ever vaping (AOR: 1.22, 95% CI = 1.10-1.36). CONCLUSIONS: Exposure to advertisements via smartphones and use of Snapchat were associated with higher rates of vaping for young adults. Social media and smartphone use should be further investigated for young adult impact.

An experimental study of messages communicating potential harms of electronic cigarettes.

There has been an upsurge of e-cigarette use in the United States in recent years. While e-cigarettes may contain lower levels of toxic chemicals than combusted cigarettes, they still pose serious health hazards, including increased risk for heart and respiratory disease. Despite these risks, public awareness of the health harms of e-cigarettes remains low. Thus, it is important to educate the public about the potential harms of e-cigarettes. This study took themes commonly found in antismoking messages and used them to develop messages about harms of e-cigarettes. A national sample of 2801 current smokers and nonsmokers (aged 18+ years) were randomized to view one of four e-cigarette messages (harmful effect of chemicals, uncertainty about ingredients, distrust of big tobacco, or cost of vaping) or a control message (bottled water ad). Participants' reactions to the messages and behavioral intentions were assessed immediately following the exposure. MANOVA examined effects of the messages on blocks of the outcome variables and univariate analyses estimated adjusted means for each experimental condition for each outcome. The message about harmful chemicals was perceived as the most informative and effective and elicited the highest levels of negative emotions (Ps<0.05). However, on measures of actual effectiveness, the other messages performed equally well. Specifically, messages with different themes (harmful chemicals, uncertainty about ingredients, anti-industry, or financial cost) increased perceived risk of e-cigarettes, support for e-cigarette control, and lowered self-exempting beliefs and intentions to use e-cigarettes (Ps<0.05). Themes commonly used in anti-smoking messages may be effective in educating the public about the potential harm of e-cigarettes. The observed differential effects of the messages suggest the need to use multiple themes in a public education campaign about e-cigarettes.

Modifications to Electronic Nicotine Delivery Systems: Content Analysis of YouTube Videos.

BACKGROUND: As user modification can alter the addictiveness and toxicity of electronic nicotine delivery systems (ENDS), more research is needed to understand the types, motivations, risks, and information sources that lead to these product alterations. YouTube has been identified as a major platform where ENDS users obtain and share information about ENDS products and modifications. However, a comprehensive study of ENDS modification videos on YouTube is lacking. OBJECTIVE: This study aimed to analyze the content of YouTube videos depicting modifications of ENDS. METHODS: YouTube was searched in March 2019 to identify videos depicting ENDS modifications. Search terms were derived from interviews with ENDS users and current literature. We used 28 search phrases that combined the words vape and vaping with modification-related key terms (eg, custom build, modification, and dripping). The final sample included 168 videos. RESULTS: Videos were 1 to 108 min long (median 9.55). Presenters were largely male (117/168, 69.6%), white (94/168, 56.0%), and older than 25 years (94/168, 56.0%). Most videos gave how to instructions (148/168, 88.1%), but few offered warnings (30/168, 17.9%) or mentioned commercial alternatives to modifications they presented (16/168, 9.5%). The ENDS devices most often featured were drippers (63/168, 37.5%) and refillable tanks (37/168, 22.0%). The most often modified ENDS components were coils (82/168, 48.8%) and e-liquids (34/168, 20.2%), which included adding other substances, such as cannabis, to the e-liquids (6/168, 3.6%). Most videos portrayed ENDS modifications positively (106/168, 63.1% positive; 60/168, 35.7% neutral; and 2/168, 1.2% negative) and were either neutral or positive in their overall portrayal of ENDS devices (78/168, 46.4% positive; 89/168, 53.0% neutral; and 1/168, 0.6% negative). CONCLUSIONS: This study identified several concerning trends in popular YouTube videos on ENDS modifications, including lack of warnings, the addition of marijuana derivatives to e-liquids, and the positive portrayal of ENDS devices and modifications. By identifying the types of modifications (coil and e-liquid being the most prevalent), this study sets an agenda for research on the effects of modifications.