Improving Enforcement Measures And Establishing Clear Criteria: A Content Analysis Of Tobacco-Brand-Owned Instagram Accounts.

INTRODUCTION: This study examines limitations of the current regulatory framework for tobacco advertising on Instagram. We first investigate compliance with FDA warning label requirements for posts by tobacco-owned accounts. Next, we examine the prevalence of content that has been restricted in broadcast or print for its youth appeal, followed by content meeting more expansive criteria for youth appeal set forth in the FDA's guidance document. METHODS: Posts by tobacco-brand-owned accounts between January 1, 2021, and February 14, 2022, were sampled from Mintel's Comperemedia Omni database. Instagram posts from 15 accounts were examined for violations of FDA warning label requirements and content that has been restricted on other mediums, including cartoons, sports branding, unauthorized claims, and young models (N=1243). Finally, a subsample of n=453 unambiguously branded posts was coded for themes that met the FDA's criteria of resonating with younger audiences, particularly that "adolescents rely on external information as they seek to shape their own identities". RESULTS: Only 12.8% of posts had fully compliant warning labels. Content that has been in some way regulated on other mediums, such as cartoons (1.6%), unauthorized health claims (<1%), sports branding (<1%), and young models (4.4%) were infrequent. However, a conservative analysis focusing only on branded posts found that posts frequently highlighted tech elements (45%), device customizability (24.5%), vaper identity (17.7%), stylized product photography (33.6%), social media engagement (32.2%) and memes (5.7%). CONCLUSIONS: Enforcement of existing regulations on Instagram is minimal. Explicit content restrictions applying evidence-based guidance on youth-appealing advertising are needed. IMPLICATIONS: This research has important implications for enforcing and expanding advertising regulations on social media. First, Instagram's self-imposed regulations are ineffective, permitting tobacco companies to post ads from brand-owned accounts despite claiming to restrict tobacco promotion on the platform. Second, policymakers should seek to apply FDA guidance on youth-appealing advertising informed by decades of research to create explicit enforceable content restrictions that extend beyond cartoons, sports figures, and young models to include content likely to situate tobacco use within the developing self-concept of vulnerable youth such as presenting e-cigarettes as hi-tech devices, highlighting vaper identity, or infiltrating online social media culture. Finally, greater resources for enforcement are needed given the only applicable regulation, warning labels, remains largely ignored.

Easy access: identification verification and shipping methods used by online vape shops.

OBJECTIVE: This project assesses how online vape shops (OVSs) verify buyer identification (ID) and the shipping methods used to send products within the USA. METHODOLOGY: In January 2023, we conducted three online searches (eg, 'best online vape shops') from our office in Washington, District of Columbia, to identify popular OVSs. Two trained coders identified discrete features available within the site sections: 'About Us', 'Shipping Policy' and 'Frequently Asked Questions', or displayed within the site's homepage. Coders recorded OVS listed locations, shipping discounts, shipping companies used and ID verification methods. Lastly, coders indicated if the site requested ID/age verification after adding an item to the shopping cart and initiating checkout procedures. RESULTS: We identified 64 unique OVSs; 92.2% (n=59) offered shipping and 82.8% (n=53) shipped to US buyers; 76.6% (n=49) allowed visitors to type a birthday or choose the '21 or older' option to access the site. Of the 59 sites shipping to buyers, 76.3% (n=45) offered free shipping, 21.9% (n=14) required login to purchase products, while most sites (n=45, 76.3%) allowed visitors to reach the checkout page without ID verification. The US Postal Service is the most commonly used shipping carrier (n=23), in violation of the Preventing All Cigarette Trafficking Act. CONCLUSIONS: Most OVSs rely on age self-certification, which underage youth can easily exploit to access these products. Findings warrant that the Food and Drug Administration, state and local policymakers explore additional actions regulating online tobacco sales to address the compliance issues our data elucidate. These include enhanced surveillance, compliance checks and stricter penalties.

Bigger, stronger and cheaper: growth in e-cigarette market driven by disposable devices with more e-liquid, higher nicotine concentration and declining prices.

OBJECTIVE: Given the evolving changes in the disposable e-cigarette market, we explore patterns of sales in the USA by e-liquid volume capacity, nicotine strength and real sales-weighted average prices by both e-cigarette unit and volume of e-liquid. METHODOLOGY: We used NielsenIQ retail scanner data from January 2017 to September 2022 to examine changes over time for average product volume capacity in millilitres, nicotine strength (%) and both sales-weighted average price per disposable unit and per millilitre of e-liquid for each 4-week period. RESULTS: Among disposable e-cigarettes sold between January 2017 and September 2022, average volume capacity increased 518% from 1.1 mL to 5.7 mL and average nicotine strength increased 294% from 1.7% to 5%. Sales-weighted average price per disposable unit and millilitres of e-liquid both remained relatively constant until January 2020. From January 2020 through September 2022, average unit prices increased 165.7% from US$8.49 to US$14.07, while the average price of 1 mL of e-liquid decreased 69.2% from US$7.96 to US$2.45. CONCLUSIONS: The current regulatory regime around e-cigarettes has resulted in disposable e-cigarette manufacturers providing consumers with bigger, cheaper disposable e-cigarettes that come in increasingly higher nicotine strengths. Tobacco policy recommendations such as restricting e-liquid capacity and minimum price laws as well as regulations on product characteristics that affect nicotine emissions and delivery such as nicotine strength, nicotine output, device power, and puff duration should be considered in regulating the e-cigarette market.

A Content Analysis of Promotional Features in US Direct-Mail From Advertisements Across Tobacco Products From 2018 to 2020.

INTRODUCTION: Direct-mail advertising is a crucial channel through which tobacco companies deliver price incentives that lower the barrier to tobacco use while promoting tobacco products via thematic appeals not legally permitted on other marketing channels. We examine the prevalence of price incentives and ad characteristics used in tobacco product advertisements (ads) mailed directly to US consumers. AIMS AND METHODS: We analyzed the content of direct-mail tobacco ads (N = 1047) in circulation between January 2018 and December 2020 as captured by Mintel Comperemedia Direct. These ads were coded for product type, manufacturer/brand type, model characteristics, price incentives, and themes known to appeal to vulnerable subgroups. RESULTS: Ads across all tobacco products included price incentives (96%) and contained themes that appealed to rural white (40%) and black audiences (15%). Themes known to appeal to youth and young adults were present in 40% of ads across all products, including 78% of ads promoting electronic nicotine delivery systems (ENDS). Moreover, the ENDS ads featuring youth appealing themes (51%), also featured young models. DISCUSSION: Expanding on previous research which focused on combustible and smokeless tobacco products, this analysis examines direct-mail ads across the full range of tobacco products. Our findings highlight the need for regulations to address (1) the high prevalence of price incentives that undermine the effectiveness of excise taxes on tobacco use, and (2) ad themes and characteristics that appeal to groups vulnerable to tobacco use, both of which have the potential to further exacerbate tobacco-related health disparities. IMPLICATIONS: This study reinforces the importance of examining direct-mail as the dominant medium for tobacco advertising, particularly by including coupons and discount codes that reduce product price and thus circumventing the effect of tobacco-related tax legislation. Direct-mail encourages continued product loyalty and use and engages new consumers using price incentives and advertising strategies likely to appeal to price-sensitive consumers and other vulnerable populations. Substantial use of youth-appealing elements in ENDS ads contradicts the tobacco industry's mandate to not appeal to youth, warranting highlighting the gaps in current regulations that allows them to continue appealing to this population.

Analysis of e-cigarette warning letters issued by the Food and Drug Administration in 2020 and 2021.

PURPOSE: This study analyses the Food and Drug Administration (FDA) warning letters sent to e-cigarette companies from 1 January 2020 to 9 September 2021. Study results can inform regulation of e-cigarettes. METHODOLOGY: Warning letters retrieved from FDA's website were coded for company type (retailer, manufacturer or distributor), location (domestic or international), infractions listed (PMTA (premarket tobacco product application), selling to minors, advertising to youth or packaging violation/mislabelling), product type (e-liquid, device or both), flavour (fruit, candy, tobacco, menthol/mint, concept flavour) and consequence (civil money penalties, product seizure and injunction, product detention and refusal of entry to the USA, no-tobacco-sales order, criminal prosecution). RESULTS: Of 303 coded letters (126 from 2020 and 177 from 2021), 97.4% were sent to small online retailers. Overall, 94.1% of the companies cited were located within the USA, 75.2% of the infractions were identified by reviewing a company's website and 70.5% were PMTA violations. In 2020, 55.6% of infractions were PMTA violations; in 2021, nearly all infractions were PMTA violations. The letters cited 880 products; 92.2% of which were e-liquid products, with 32.4% fruit and 31.1% concept flavours. DISCUSSION: Warning letters targeted small online retailers rather than large e-cigarette brands or products most used by youth: pod mods and disposables. The focus of these enforcement actions comprises a small share of the market and the impact on use was likely minimal. With PMTA decisions pending for the largest brands of e-cigarettes, the FDA should use its enforcement powers to target manufacturers, distributors and sellers of the tobacco products that have the greatest impact on youth and products that provide no public health benefit.

The impact of two state-level approaches to restricting the sale of flavored tobacco products.

BACKGROUND: Flavored tobacco products are highly appealing to youth. The Federal government lacks a comprehensive flavored tobacco products policy and states have adopted different approaches restricting these products. This study analyzes the impact of Massachusetts' comprehensive prohibition and New Jersey's partial restriction on the sale of flavored tobacco products. METHODS: NielsenIQ Retail Scanner data were used to construct four log per capita dependent variables: e-liquid milliliters, cigarette packs, cigars, and smokeless tobacco ounces for products flavored as fruit, menthol, mint, tobacco and other. All models used difference-in-differences regressions, with Virginia and Pennsylvania serving as controls. The models controlled for state level product prices, population percentages by race/ethnicity, proportion male, median household income, unemployment rate, minimum legal sales age, tobacco 21 policies, and cumulative cases and deaths of COVID-19; the models accounted for time-specific factors by using 4-week period fixed-effects. RESULTS: There was a significant decrease in sales across all flavored tobacco products in Massachusetts, including fruit [-99.83%, p < 0.01], menthol [-98.33%, p < 0.01], and all other flavored [-99.28%, p < 0.01] e-cigarettes. The cigar group "all other-flavors" [-99.92%, p < 0.01] and menthol flavored cigarettes [-95.36%, p < 0.01] also significantly decreased. In New Jersey, there was a significant decrease in per capita sales of menthol-flavored e-cigarettes [-83.80%, p < 0.05] and cigar group "all other-flavors" experienced a significant increase in per capita sales [380.66%, p < 0.01]. CONCLUSIONS: This study contributes to the growing body of evidence demonstrating the impact of sales prohibitions on reducing sales of flavored tobacco products. Statewide comprehensive approaches appear more effective than partial restrictions and should be prioritized. IMPLICATIONS: Results from this study support emerging research that demonstrates the promising effects of comprehensive flavoring sales prohibitions. This study can be used to inform future flavored tobacco product policy solutions developed by advocates and policy makers to curb overall tobacco initiation and use by youth and adults.

Interest in Receiving Nutrition Information Through Social Media Among Food-Security Program Participants in Washington, DC.

INTRODUCTION: Effective communication approaches are necessary to reach food-security program participants. Accessing food-security programs has been especially challenging during the COVID-19 pandemic. Social media can play an important role in reducing some communication barriers. We examined interest in receiving nutrition information via social media among adults participating in food-security programs in Washington, DC. METHODS: We developed and administered a 22-item survey to adults participating in food-security programs (N = 375). Participants were recruited at Martha's Table, in Washington, DC, from January through March 2020. We performed bivariate analyses and multinomial logistic regressions to examine predictors of interest in receiving nutrition information via social media. RESULTS: Sixty-nine percent of participants reported using social media, and 49% expressed interest in receiving nutrition information via social media. Higher levels of self-efficacy and belief in the value of digital technology were associated with greater likelihood of interest in receiving nutrition information via social media (χ2 6 = 139.0; Nagelkerke R2 = 0.35; P < .001). We found no differences by sex or digital technology access in interest in receiving nutrition information via social media. CONCLUSION: Social media is a widely used and a feasible method to reach food-security program participants. Understanding program participants' interest in receiving health information via social media may help food-security programs plan effective communication strategies to improve food security, especially when in-person participation is limited, such as during the COVID-19 pandemic.

E-Cigarette Brand Trends in the United States: An Investigation of Data From a Youth and Young Adult Sample and the E-Cigarette Retail Market (2022).

Background: Electronic cigarettes (e-cigarettes) remain the most used tobacco product among young people in the United States (US). Given the need for current data on popular e-cigarette products, the current study leverages data from a rapid surveillance survey of young people and examines whether the top e-cigarette brands identified from this source align with US market data. Methodology: Data were obtained from current e-cigarette users (N = 4145) participating in the Truth Continuous Tracker Online (CTO; a cross-sectional tracking survey of 15-24 year-olds sourced from the national Dynata panel) and NielsenIQ retail scanner data, collected in 2022 and aggregated by quarter (Q1, Q2, and Q3). The top 15 e-cigarette brands were determined from respondents' endorsement in the Truth CTO and ranked total sales in NielsenIQ in nominal dollars. Results: Overall, 58% of e-cigarette brands overlapped across the Truth CTO and NielsenIQ data (60% for Q1, 47% for Q2 and 67% for Q3). Pod-based (JUUL; VUSE) and disposable (Hyde; Breeze Smoke) brands appeared as top brands in both datasets. Top brands were fairly consistent within and across quarters; though, more variability was found in the Truth CTO, relative to NielsenIQ. Many top brands were disposable. Conclusions: Results suggest that data from rapid surveillance and retail data can be used complementarily to characterize the popular e-cigarette brands currently on the US market. Many of these popular e-cigarette brands have yet to receive marketing granted orders under the US Food and Drug Administration, suggesting the need to continue monitoring e-cigarette brands among young people.

Examining influencer compliance with advertising regulations in branded vaping content on Instagram.

Background: Youth and young adults are exposed to vaping advertisements on social media sites, despite regulations and guidelines intended to reduce the prevalence of such content on these platforms. This research uses replicable criteria to identify vaping influencers who have worked with vaping brands to promote vaping products on Instagram and documents the extent to which posts by these users comply with existing advertising regulations. Methodology: We conducted three google searches collecting eight different vaping influencer lists, with a total of 575 unique influencers. We limited our sample to public accounts with 100,000 followers or more (n = 54). An initial sample of 360 Instagram posts was used to identify an analytic sample of 262 vape-related posts from 2021. We conducted a conceptual content analysis to first identify unambiguous vaping advertisements (branded content), and then code ads for compliance with existing regulations. Results: On average, the 54 Instagram accounts had 265,851.9 followers (sd = 383,349.8) and 4,158 posts (sd = 7,302.1). Most posts featured vaping products 239 (91.2%), with 186 (76.2%) posts being unambiguously branded vape advertisements and 31 (14.3%) even including purchase links in the post itself. However, one post complied with FTC disclosure guidelines. Although 50 (20.9%) had warning labels, only 8 (15.1%) were fully compliant with FDA warning label guidelines. Discussion: Findings demonstrate minimal compliance with existing regulations among influencers known to have financial relationships with vaping brands. Most influencer posts are unambiguous, branded, vaping advertisements. Implications for barriers to regulating influencer content and the need for greater enforcement resources are discussed.

In Their Own Words: Parents and Key Informants' Views on Nutrition Education and Family Health Behaviors.

Parents, health professionals, and communities are integral in the development of nutrition behaviors that reduce children's risk for high body mass index (BMI) and chronic disease. The aim of this study was to conduct formative evaluations with key health informants and parents to understand the specific strategies that families use at mealtimes to promote their family's health, along with the barriers they face in attending current nutrition education programming. Focus groups (in English and Spanish) were conducted with parents (n = 22; 63.64% Black/African American, 13.64% Black but not African American, 18.18% Hispanic/Latinx) whose household was located in a community where 50% of residents' gross income was ≤185% of the federal poverty level. Semi-structured interviews were conducted with six key informants with expertise in family health and nutrition. Inductive thematic analysis was used to identify themes across interviews. Six general themes emerged from the interviews including perceptions of health, relationships, health behaviors, facilitators, barriers, and desired changes. Across the six themes, participants responded with suggestions for community-based health promotion programs such as incorporating a broader definition of health to better address the individual and systemic barriers that perpetuate health inequities and make healthy eating difficult. Participants identified stress reduction, health literacy, and cooking knowledge as areas of interest for future programming.