In a recent study published in the journal Dr Tobacco related diseases, researchers conducted a four-country cross-sectional online survey to assess youth exposure to media-based e-cigarette advertising. Despite World Health Organization (WHO) recommendations and national legislatures limiting e-cigarette advertising, the study found that 85% of sampled youth were exposed to one or more modes of e-cigarette advertising. The study further investigated the relationship between media exposure and e-cigarette use and found a significant relationship between these variables.
Study: Exposure to e-cigarette advertising and youth e-cigarette use: a four-country study. Image credit: Created with assistance from DALL·E 3
What are e-cigarettes and why are they controversial?
Electronic cigarettes, also called “e-cigs,” “vapes,” “e-hookahs,” “vape pens,” and “electronic nicotine delivery systems (ENDS), are battery-operated devices that mimic smoking tobacco. Smoking conventional cigarettes is healthier Despite the popularity of e-cigs as an alternative, studies have identified significant neurological and cardiovascular damage and an increased risk of nicotine addiction, particularly among children, adolescents and young adults, as a result of their use.
Global efforts and regulations: are they enough?
Based on this research, the World Health Organization (WHO) recommended banning all forms of e-cig advertising, sponsorship and promotion. The WHO Framework Convention on Tobacco Control, adopted as part of the 56th World Health Assembly in Geneva, Switzerland on 21 May 2003, requires all signatories to implement the ban. However, although most national legislatures have been updated to incorporate these regulatory policies, a growing body of evidence indicates continued advertising, particularly on the Internet and other hard-to-monitor digital media sources.
This is concerning, especially given that anecdotal evidence suggests an inverse relationship between youth harm perception (a function of media exposure) and e-cig use. However, few studies have aimed to formally investigate specific forms of media exposure and the possible additive effects of multiple or prolonged advertisements on e-cig outcomes, with research limited to the United States (US).
The Study Design: Investigating Media Exposure Across Four Countries
In the current study, researchers aimed to investigate young adults (18–30 years old), different forms of media exposure, and any possible relationship between e-cig use and amount of exposure. The online cross-sectional study was conducted in four countries with different ethnicities and a spectrum of e-cig laws.
“India has one of the strictest regulatory environments in the world: nicotine and non-nicotine e-cigarettes are banned and advertising is not allowed. The four countries that make up the UK have the most liberal laws.”
Australia and China represent a middle ground between the laws of the remaining two countries, India and the United Kingdom (UK) – Australia allows the sale of non-nicotine e-cigs and nicotine e-cigs with a prescription. China allows adults (≥18 years) to purchase nicotine e-cigs. Both countries have banned e-cig advertising through the media.
The sample group included ~1,000 survey respondents per race across four countries, with care taken to ensure balanced male and female representation. A blinded (participants did not know the content of the study before receiving it) 15-minute long questionnaire was administered between November and December 2021. About 82% of respondents completed the survey, but 8% were removed from the analysis following quality assessment.
In addition to questions regarding e-cig knowledge, use, and media exposure, the questionnaire collected information on participant demographics, including gender, age, educational level, and income. Drawing from the US National Youth Tobacco Survey, the researchers identified and listed 24 forms of media. To assess the association between media exposure and multiple modes of e-cig use, study participants were asked to report the number of forms that applied to them.
Statistical analysis consisted of chi-square test and mixed effect logistic regression model. The models were correct for country-specific clustering.
Key findings: Effects of media exposure on vaping rates
Of the 4,107 participants included in the study, 1,011 reported a lack of knowledge about e-cigarettes. These participants were mainly from China (50%) and India (35%). About 85% of respondents with knowledge of e-cigs reported at least one form of media exposure, a figure higher in the user group (95%) than among respondents who did not use e-cigs (79%).
Assessment of methods of media exposure revealed an average of five forms per respondent, with more exposure found on social media platforms such as Duyin (China – 50%) and Instagram (Australia/India/UK – 39%) compared to the general internet. Browsing (29%).
Logistic regression models revealed that the odds of e-cig use increased by 5% for each additional mode of media exposure. Other significant factors associated with e-cig consumption include being a current or former tobacco smoker or having a friend or family member who uses e-cigs. Male participants were also found to be more likely to vape than their female counterparts.
Conclusion: Stricter regulation is urgently needed
The present study investigates the number of modes of media exposure related to e-cigs and how this exposure translates into e-cig uptake among young adults aged 18–30 years. The survey comprised more than 4,000 respondents across India, China, Australia and the UK, revealing that 85% of respondents had been exposed to at least one form of e-cig-promoting media. Modes of exposure were largely online and primarily centered on social media platforms such as Dwayne and Instagram.
Alarmingly, each unit of media exposure was associated with a 5% increased likelihood of vaping intake. This study highlights the importance of banning advertising across countries and, where applicable, cross-border policies to curb the online spread of e-cig-promoting media.