E-cigarette and Cannabis in Social Media Influencer Marketing and Its Effect on Adolescents: A Survey-Based Experiment

Adolescents are exposed to e-cigarette and cannabis content on social media. Understanding associations of these exposures with use and dual use of these products can guide regulations. To assess whether adolescent exposure to e-cigarette and/or cannabis content on social media, including posts by various content creators, is associated with e-cigarette, cannabis, and dual use. Two surveys, one longitudinal (study 1, baseline in 2021 to 2022) and one cross-sectional (study 2, fall 2023), were conducted among California high school students who completed questionnaires on computers in classrooms. In study 1, the baseline was frequent exposure (weekly or more vs less frequent or none) to e-cigarette and/or cannabis social media posts. In study 2, the exposure (yes vs no) was to e-cigarette and/or cannabis posts from specific sources (friends, celebrities, microinfluencers, e-cigarette and/or cannabis brands, or unknown sources). For study 1, the primary outcome was solo e-cigarette, solo cannabis, or dual use initiation at 1-year follow-up among baseline never-users of e-cigarettes and cannabis. For study 2, the primary outcome was past-month use of e-cigarettes, cannabis, and dual use. Generalized estimating equations models adjusted for sociodemographic characteristics, mental health, other tobacco product use, social media use, and social environment. In study 1, of 4232 adolescents (mean [SD] age, 17.0 [0.6] years; 2205 female [52.1%]), 968 (22.9%) reported frequent baseline exposure to e-cigarette posts and 507 (12.0%) reported exposure to cannabis posts on social media, broadly; 567 (13.4%) were frequently exposed to e-cigarette posts specifically on TikTok. Frequent exposure to cannabis social media posts was associated with solo e-cigarette use (adjusted odds ratio [AOR], 1.83; 95% CI, 1.11-3.01), solo cannabis use (AOR, 1.60; 95% CI, 1.07-2.38), and dual use (AOR, 1.71; 95% CI, 1.11-2.63) initiation at 1-year follow-up. Frequent exposure to e-cigarette posts on TikTok was associated with solo cannabis use (AOR, 1.74; 95% CI, 1.17-2.58) and dual use (e-cigarette and cannabis) initiation (AOR, 1.78; 95% CI, 1.19-2.66). In study 2, of 3380 adolescents (mean [SD] age, 17.0 [0.6] years; 1840 female [54.4%]), 195 (5.8%) were exposed to microinfluencer e-cigarette posts, and 152 (4.5%) were exposed to microinfluencer cannabis posts; 151 (4.5%) were exposed to friends' e-cigarette posts, and 161 (4.8%) were exposed to friends' cannabis posts. Exposure to e-cigarette (AOR, 2.67; 95% CI, 1.55-4.59) and cannabis (AOR, 2.14; 95% CI, 1.15-4.00) microinfluencer posts was associated with past-month cannabis use. Exposure to friends' e-cigarette posts was associated with past-month dual use (AOR, 2.53; 95% CI, 1.24-5.19), whereas exposure to friends' cannabis posts was associated with past-month cannabis use (AOR, 3.35; 95% CI, 1.94-5.78) and dual use (AOR, 2.46; 95% CI, 1.28-4.71). In this survey study of California adolescents, exposure to e-cigarette or cannabis posts was associated with adolescent e-cigarette, cannabis, or dual use. Improvement of social media community guidelines and greater policy attention to co-use and marketing of e-cigarettes and cannabis may help prevent youth substance use.

E-cigarettes have emerged as a popular alternative to traditional tobacco products, raising concerns about the potential public health impact of widespread exposure to e-cigarette content. This scoping review aimed to answer the question: 'Is there an association between exposure to e-cigarette content on social or traditional media and product use among individuals?'. The review was conducted in accordance with PRISMA-ScR guidelines. A literature search was performed in MEDLINE (PubMed), Cochrane, EMBASE, and ScienceDirect on 30 July 2023, including studies published from 2004 to July 2023. Only studies in English were included, focusing on participants exposure to e-cigarettes via media platforms. The review examined self-reported exposure to organic posts and promotions, with outcomes related to e-cigarette use (lifetime/ever and current/past 30-day use). The review also explored trends in media advertising and e-cigarette use during that period. The marketing platforms assessed included social media (Instagram, YouTube, Reddit, Facebook, Twitter, and Snapchat, websites), traditional media (television, movies, radio), and print media (magazines, newspapers). Of the 30 studies included in this review, 14 were longitudinal in design. The majority were conducted in the United States (n=27), with one study each from China, Germany, and Scotland. The prevalence of current and ever e-cigarette users varied across different regions and populations. The majority of studies covered in the review observed a significant association between e-cigarette marketing exposure and product use among various demographic groups. Multiple US national studies reported an upward trend in e-cigarettes use from 2011 to 2019. Longitudinal studies indicated a temporal relationship between e-cigarette marketing and subsequent product use, particularly among youth. This scoping review highlights the evolving landscape of e-cigarette media advertising and its potential correlation on product use. Exposure to e-cigarette content on traditional and social media was consistently associated with e-cigarette consumption among diverse populations.

High International Electronic Cigarette Use Among Never Smoker Adolescents

To what extent does time spent on social media influence adolescent use of cigarettes and e-cigarettes: a longitudinal analysis of the UK Millennium Cohort Study

Adolescent e-cigarette use is a global epidemic with significant public health concerns. Millions of adolescents worldwide use e-cigarettes, and social media is believed to be a contributing factor. This review summarizes research on social media’s influence on adolescent e-cigarette use. PubMed, CINAHL, PsycINFO, and Scopus databases were used for article searching. Inclusion criteria were peer-reviewed articles written in English that examined the impact of social media on adolescent e-cigarette use. The Mixed Methods Appraisal Tool was used to evaluate the quality of the studies. The study followed the PRISMA-ScR guidelines for scoping reviews. A total of 24 studies were reviewed, including 21 quantitative and 3 qualitative. Results were categorized into eight (8) themes: 1) frequency of social media use; 2) engagement with e-cigarette brand pages; 3) e-cigarette discussions; 4) frequency of exposure to e-cigarette content; 5) e-cigarette harm perception; 6) gateway to learning about e-cigarettes; 7) exposure to anti-e-cigarette use-related content; and 8) exposure to pro-e-cigarette use-related content. The findings suggest that exposure to e-cigarette content on social media impacts adolescent e-cigarette use, with social media use frequency being strongly associated. It shapes adolescents’ perceptions, beliefs, and intent to use e-cigarettes. Social media strongly impact adolescent e-cigarette use, normalizing and promoting it. E-cigarette marketing and user-generated content on social platforms make it appealing and seem harmless to adolescents. Policymakers, healthcare providers, and public health organizations need to address this issue.

The prevalence of electronic cigarette (e-cigarette) use is increasing. Population health effects will depend on cigarette smoking behaviors, levels of dual use with conventional cigarettes, and e-cigarette toxicity. To evaluate potential health effects of various scenarios of increasing promotion and use of e-cigarettes. A base case model was developed using data on actual cigarette and e-cigarette use patterns that quantifies transitions from an initial state of no cigarette or e-cigarette use to 1 of 5 final states: never use of cigarettes or e-cigarettes, cigarette use, e-cigarette use, dual use of cigarettes and e-cigarettes, or quit. Seven scenarios were created that cover a range of use patterns, depending on how the e-cigarette market might develop, as well as a range of possible long-term health effects of e-cigarette use. Scenarios for changes from the base case were evaluated using Monte Carlo simulations. Separate sets of base case model parameters were evaluated for the US and UK populations. We assigned unitless health "costs" for each final state on a scale of 0 to 100. Population health "costs" were compared with the base case (status quo) assuming e-cigarette use health "costs" from 1% to 50% as dangerous as conventional cigarette use health costs. Compared with the base case, a harm reduction scenario in which e-cigarette use increases only among smokers who are interested in quitting with more quit attempts and no increased initiation of e-cigarette use among nonsmokers, and another scenario in which e-cigarettes are taken up only by youth who would have smoked conventional cigarettes, had population-level health benefits regardless of e-cigarette health costs in both the United States and United Kingdom. Conversely, scenarios in which e-cigarette promotion leads to renormalization of cigarette smoking or e-cigarettes are used primarily by youth who never would have smoked showed net health harms across all e-cigarette health costs. In other scenarios, the net health effect varied on the basis of the health cost of e-cigarettes. According to this analysis, widespread promotion of e-cigarettes may have a wide range of population-level health effects, depending on both e-cigarette health risks and patterns of use. Absent the primary effect of e-cigarette promotion being only to divert current or future conventional cigarette smokers to e-cigarette use, the current uncertainty about the health risks of e-cigarettes, increasing e-cigarette use among youth, and the varying health effects at different e-cigarette health costs suggest a potential for harm.

FigureElectronic cigarettes, or e-cigarettes, are battery-powered devices that provide doses of nicotine and other additives to the user in an aerosol. Depending on the brand, e-cigarette cartridges typically contain nicotine, a component to produce the aerosol (e.g., propylene glycol or glycerol), and flavorings (e.g., fruit, mint, or chocolate).1 Potentially harmful constituents also have been documented in some e-cigarette cartridges, including irritants, genotoxins, and animal carcinogens.1 E-cigarettes that are not marketed for therapeutic purposes are currently unregulated by the Food and Drug Administration, and in most states there are no restrictions on the sale of e-cigarettes to minors. Use of e-cigarettes has increased among U.S. adult current and former smokers in recent years,2 but the extent of use among youths is uncertain. Data from the 2011 and 2012 National Youth Tobacco Survey (NYTS), a school-based, pencil-and-paper questionnaire given to U.S. middle school (grades 6–8) and high school (grades 9–12) students, were used to estimate the prevalence of ever and current (one or more per day in the past 30 days) use of e-cigarettes, ever and current (one or more per day in the past 30 days) use of conventional cigarettes, and use of both. The survey consists of a cross-sectional, nationally representative sample of students in grades 6–12 from all 50 states and the District of Columbia.3 During 2011–2012, among all students in grades 6–12, “ever” e-cigarette use increased from 3.3 to 6.8 percent (p<0.05); current e-cigarette use increased from 1.1 to 2.1 percent (p<0.05); and current use of both e-cigarettes and conventional cigarettes increased from 0.8 to 1.6 percent (p<0.05). In 2012, among ever e-cigarette users, 9.3 percent reported never smoking conventional cigarettes; among current e-cigarette users, 76.3 percent reported current conventional cigarette smoking.Figure: Ever electronic cigarette (e-cigarette) use among middle and high school students, by year, in the United States during 2011–2012. During that time, among all students in grades 6–12, ever e-cigarette use increased from 3.3% to 6.8%; current e-cigarette use increased from 1.1% to 2.1%, and current use of both e-cigarettes and conventional cigarettes increased from 0.8% to 1.6%.Among middle school students, ever e-cigarette use increased from 1.4 to 2.7 percent during 2011–2012 (p<0.05); current e-cigarette use increased from 0.6 to 1.1 percent (p<0.05); and current use of both e-cigarettes and conventional cigarettes increased from 0.3 to 0.7 percent (p<0.05). In 2012, among middle school ever e-cigarette users, 20.3 percent reported never smoking conventional cigarettes; among middle school current e-cigarette users, 61.1 percent reported current conventional cigarette smoking. Among high school students, ever e-cigarette use increased from 4.7 to 10.0 percent during 2011–2012 (p<0.05); current e-cigarette use increased from 1.5 to 2.8 percent (p<0.05); and current use of both e-cigarettes and conventional cigarettes increased from 1.2 to 2.2 percent (p<0.05). In 2012, among high school ever e-cigarette users, 7.2 percent reported never smoking conventional cigarettes; among high school current e-cigarette users, 80.5 percent reported current conventional cigarette smoking. Use Doubled E-cigarette experimentation and recent use doubled among U.S. middle and high school students during 2011–2012, resulting in an estimated 1.78 million students having ever used e-cigarettes as of 2012. Moreover, in 2012, an estimated 160,000 students who reported ever using e-cigarettes had never used conventional cigarettes. This is a serious concern because the overall impact of e-cigarette use on public health remains uncertain. In youths, concerns include the potential negative impact of nicotine on adolescent brain development,4 as well as the risk for nicotine addiction and initiation of the use of conventional cigarettes or other tobacco products. CDC and the Food and Drug Administration will continue to explore ways to increase surveillance and research on e-cigarettes. Given the rapid increase in use and youths' susceptibility to social and environmental influences to use tobacco, developing strategies to prevent marketing, sales, and use of e-cigarettes among youths is critical. Reprinted (slightly edited) from Morbidity and Mortality Weekly Report 2013; 62:729–730

Adolescents' exposure to electronic cigarette (e-cigarette) content through social media platforms influences their perceptions and behaviors, although cross-country analyses in different regulatory environments are scarce. This study evaluated the association between e-cigarette exposure on social media platforms and e-cigarette susceptibility and use in Jalisco (Mexico) and Southern California (United States). In 2022-2023, students from 23 high schools in Jalisco (n=1418) and 11 in Southern California (n=2953) were surveyed with harmonized measures on past-month frequency of social media platform use (ie, YouTube [Google], Instagram [Meta], TikTok [ByteDance], Snapchat [Snap Inc], WhatsApp [Meta], Facebook [Meta], Twitter (now "X"), and Twitch [Twitch Interactive]) and seeing e-cigarette posts on each social media platform used; which were recoded to 5-point scores (range 0-4) for social media platforms use and e-cigarette post exposure. Country-stratified logistic models regressed e-cigarette susceptibility (among noncurrent users) and past-month use on social media platform scores, adjusting for age, sex, family affluence, and friends' e-cigarette use. Past-month e-cigarette use was higher in Jalisco (248/1418, 17.5%) than Southern California (139/2953, 4.7%; P<.001). Social media use and e-cigarette exposure on each social media platform differed across samples (P values<.001). In Southern California, more frequent social media use was positively associated with e-cigarette susceptibility (adjusted odds ratio [AOR] 1.83, 95% CI 1.48-2.25), whereas in Jalisco, higher frequency of exposure to e-cigarette content was associated with susceptibility (AOR 1.21, 95% CI 1.02-1.43). Higher frequency of social media use and exposure to e-cigarette content were both positively associated with past-month e-cigarette use in Southern California; in Jalisco, greater exposure to social media platforms and e-cigarette content was associated with past-month use. Frequent social media platform use and e-cigarette exposure through social media platforms appear to be associated with e-cigarette susceptibility and use across contexts. Stronger policies to limit and enforce online exposures are needed.

JUULing Epidemic Among Youth: A Guide to Devices, Terminology, and Interventions.

Social media e-cigarette exposure and e-cigarette expectancies and use among young adults

This study tested whether exposure to e-cigarette advertising increases e-cigarette use susceptibility among nonsmoking young adults by promoting explicit and implicit attitudes toward e-cigarettes as a safer and healthier alternative to combustible cigarettes. Young adult current nonsmokers who had never used an e-cigarette (n = 393; mean age = 22.1, standard deviation = 3.9; 66% women) were randomly assigned to one of the three conditions that involved viewing real-world, print e-cigarette ads. Two of the three conditions were experimental conditions where ads with different predominant themes (harm reduction ["Health"] versus social enhancement ["Social"] focused) were interspersed among ads of everyday objects. The third condition was the Control condition involving ads of everyday objects only. Participants provided data on explicit (ie, self-reported harm perceptions) and implicit (ie, Implicit Association Test) attitudes toward e-cigarette use and e-cigarette use intentions. Hypotheses were tested using structural equation modeling. Relative to Control participants, participants in Health and Social conditions were more likely to show higher implicit attitudes toward e-cigarettes as a safer alternative to cigarettes. Only the Social condition, relative to Control, had a significant effect on lower explicit harm perceptions of e-cigarette versus cigarette use. The Social condition had a significant indirect effect on e-cigarette use susceptibility, mediated by explicit harm perceptions. Social enhancement-themed ads may communicate the reduced harm messages more strongly among young adults so as to affect both explicit and implicit attitudes and, through these, e-cigarette use susceptibility. Regulatory bodies may need to scrutinize reduced harm claims communicated through social enhancement-themed ads. The findings imply that implicit and explicit health benefit or reduced harm claims in e-cigarette marketing may be propagated via ads that use social enhancement gimmicks to attract youth and young adults. As the US Food and Drug Administration develops regulations on e-cigarette marketing, informed decisions need to be made that address harm reduction needs of current smokers as well as e-cigarette use onset among nonsmokers. In regard to the latter, e-cigarette marketing may need to be studied closely to monitor implicit and explicit health benefit claims that are coupled with the use of visual and textual gimmicks in ads that intend to make e-cigarettes more appealing to youth and young adults.

To identify who were social media active e-cigarette users, to compare the use patterns from both survey and social media data for data triangulation, and to jointly use both datasets to conduct a comprehensive analysis on e-cigarette future use intentions. We jointly used an e-cigarette use online survey (n = 5132) and a social media dataset. We conducted analysis from 3 different perspectives. We analyzed online forum participation patterns using survey data. We compared e-cigarette use patterns, including brand and flavor types, ratings, and purchase approaches, between the 2 datasets. We used logistic regression to study intentions to use e-cigarettes using both datasets. Male and younger e-cigarette users were the most likely to participate in e-cigarette-related discussion forums. Forum active survey participants were hardcore vapers. The e-cigarette use patterns were similar in the online survey data and the social media data. Intention to use e-cigarettes was positively related to e-liquid ratings and flavor ratings. Social media provided a valuable source of information on users' ratings of e-cigarette refill liquids. For hardcore vapers, social media data were consistent with online survey data, which suggests that social media may be useful to study e-cigarette use behaviors and can serve as a useful complement to online survey research. We proposed an innovative framework for social media data triangulation in public health studies. We illustrated how social media data, combined with online survey data, can serve as a new and rich information source for public health research.

E-cigarette use among youth in China

This study analyzed the relationship between social media use, perceptions of harm, demographic factors, and the likelihood of electronic cigarette use in middle and high school students in the United States, using data from the 2023 National Youth Tobacco Survey (NYTS). A total of 22 069 students participated in the 2023 NYTS, with 16 845 included in the final analysis after excluding those with missing data. The survey collected self-reported data on e-cigarette use, social media engagement, perceptions of harm and addictiveness, and environmental exposure to e-cigarettes. Adjusted odds ratios (OR) were calculated to assess the association between these factors and e-cigarette use. Two thousand four hundred ninety-eight students (14.8%) reported ever using e-cigarettes, with older students showing significantly higher odds of e-cigarette use than younger students. Non-Hispanic Black and other racial groups had lower odds of e-cigarette use compared to non-Hispanic White students. Adolescents who perceived e-cigarettes as more harmful or more addictive than cigarettes were less likely to have used them. Social media behaviors were also strongly associated with e-cigarette use, with students who used social media less frequently having lower rates of e-cigarette use. Other social media related findings showed that students who frequently saw, posted, or interacted with e-cigarette-related content were significantly more likely to try e-cigarettes. Exposure to e-cigarette use at home and in vehicles further increased the likelihood of use. This study highlights the influence of social media exposure, perceptions of harm, and demographic factors on adolescent e-cigarette use. Older students and those with greater exposure to e-cigarette-related content on social media are at higher risk for e-cigarette experimentation. Public health efforts should focus on addressing social media influences, correcting misperceptions about peer use, and educating adolescents on the risks of e-cigarette use to mitigate this growing public health concern.

Youth Social Media Use and Health Outcomes: #diggingdeeper