Research Article
A Randomized Trial of the Effect of E-cigarette TV Advertisements on Intentions to Use E-cigarettes

https://doi.org/10.1016/j.amepre.2015.05.010Get rights and content

Introduction

Adolescents’ use of electronic cigarettes (e-cigarettes) and exposure to e-cigarette TV advertising have increased in recent years, despite questions about their safety. The current study tests whether exposure to e-cigarette TV advertisements influences intentions to use e-cigarettes in the future and related attitudes.

Methods

A parallel-group randomized controlled experiment was conducted and analyzed in 2014 using an online survey with a convenience sample of 3,655 U.S. adolescents aged 13–17 years who had never tried e-cigarettes. Adolescents in the treatment group viewed four e-cigarette TV advertisements.

Results

Adolescents in the treatment group reported a greater likelihood of future e-cigarette use compared with the control group. ORs for the treatment group were 1.54 (p=0.001) for trying an e-cigarette soon; 1.43 (p=0.003) for trying an e-cigarette within the next year; and 1.29 (p=0.02) for trying an e-cigarette if a best friend offered one. Adolescents in the treatment group had higher odds of agreeing that e-cigarettes can be used in places where cigarettes are not allowed (OR=1.71, p<0.001); can be used without affecting those around you (OR=1.83, p<0.001); are a safer alternative to cigarettes (OR=1.19, p=0.01); and are less toxic (OR=1.16, p=0.03).

Conclusions

Exposure to e-cigarette advertising had relatively large and consistent effects across experimental outcomes. Together with the simultaneous increase in e-cigarette advertising exposure and e-cigarette use among adolescents, findings suggest that e-cigarette advertising is persuading adolescents to try this novel product. This raises concerns that continued unregulated e-cigarette advertising will contribute to potential individual- and population-level harm.

Introduction

Electronic cigarette (e-cigarette) use has risen rapidly in the U.S. in recent years. U.S. sales of e-cigarettes have doubled every year since they were introduced, reaching $2 billion annually in 2013.1 In 2012, 32% of U.S. smokers aged 18 years or older had tried e-cigarettes at least once.2 One year later, ever use of e-cigarettes increased markedly to 50% among daily smokers and 44% among non-daily smokers.3 Concurrent with recent increases among adults, adolescent use of e-cigarettes has risen. From 2013 to 2014, current use of e-cigarettes (past 30 days) tripled among U.S. high school students (4.5%–13.4%) and middle school students (1.1%–3.9%).4 Similar data from Florida show steeply rising trends in use among high school students from 2011 to 2014; ever use jumped from 6.0% in 2011 to 20.5% in 2014, and current use increased from 3.1% to 10.8%.5 In 2014, 30.3% of Florida high school students and 42.2% of middle school students who reported ever use of e-cigarettes had never tried traditional cigarettes.5

Despite the rapid growth of e-cigarette use, many questions remain about their safety.6 Adolescent exposure to nicotine has negative effects on brain development,7 with deficits shown in executive functions as well as increased anxiety and depression.7, 8, 9 Adolescence is a period of enhanced vulnerability to the reinforcing effects of nicotine,10 raising serious concerns about nicotine exposure through e-cigarette use. There is also concern that adolescents who have been introduced to the effects of nicotine in e-cigarettes may be more susceptible to trying conventional cigarettes.6 Currently, e-cigarettes are unregulated at the federal level, but the U.S. Food and Drug Administration (FDA) announced a proposed rule in April 2014 to regulate e-cigarettes as a tobacco product.11 The proposed rule does not include any restrictions on e-cigarette advertising and marketing.

The increases in adult and adolescent e-cigarette use in the U.S. have occurred during a short period of time during which e-cigarette advertising has increased dramatically. Total e-cigarette advertising increased from $6.4 million in 201112 to $82 million in 2013.13 Over this same period, adolescents’ exposure to e-cigarette TV advertising increased by more than 250%, with the sharpest increase occurring in 2013 as the result of new, large national advertising campaigns.14 Almost 60% of adolescents aged 12–17 years were exposed to e-cigarette advertising in 2013.13

Although an established evidence base indicates that conventional cigarette advertising increases smoking intentions, initiation, and consumption among adolescents,15 there is currently no direct evidence of similar effects for e-cigarette advertising. After viewing advertisements, one study found that 66% of adult smokers intend to try e-cigarettes in the future.16 Pepper and colleagues17 created and experimentally tested e-cigarette advertising messages and images among adult smokers who had never tried e-cigarettes. They found that advertisements highlighting the differences between cigarettes and e-cigarettes (e.g., lower cost, healthier) or featuring an image of someone using an e-cigarette increased intentions to try e-cigarettes compared with a control condition.

Given FDA’s concern that significant rates of e-cigarette use by U.S. adolescents could have a negative effect on public health,11 it is critical to determine the extent to which exposure to e-cigarette advertising affects adolescent e-cigarette use. The current study is the first to examine the effects of viewing e-cigarette TV advertisements on adolescents aged 13–17 years in a randomized controlled experiment. The primary goal of the study is to test whether exposure to e-cigarette TV advertisements influences intentions to use e-cigarettes in the future and related attitudes, especially among youth who have never tried e-cigarettes.

Section snippets

Experimental Design

In May 2014, a total of 5,020 adolescents aged 13–17 years completed an online survey. Respondents were age-eligible youth living in the household of adults in a national online survey panel. The online panel recruits panel members using convenience sampling methods, such as web-based advertising and a broad variety of loyalty programs. The online panel uses a quality assurance system to verify identities of potential panelists (i.e., potential participants must confirm their e-mail address

Results

Table 1 presents the sample characteristics overall and by experimental condition. Consistent with the random assignment, only modest differences were found in the distribution of race and current smoking status between the treatment and control groups, which was controlled for in subsequent analyses.

Adolescents in the treatment group reported a greater likelihood of future e-cigarette use compared with the control group (Figure 2). ORs for the treatment group ranged from 1.54 (p=0.001) for

Discussion

In 2013, $80 million in e-cigarette advertising led to unprecedented levels of adolescent exposure to televised messages publicizing the benefits of e-cigarettes. The current experiment showed that a single exposure to four such advertisements by adolescents who had not previously used e-cigarettes resulted in more-favorable attitudes and intentions to try e-cigarettes, which were 50% higher than the control group. This study found that current cigarette smoking was a strong predictor of

Acknowledgments

MF contributed to the study design, instrument development, and analyses and wrote the first draft of the manuscript. JD, EC, ME, and JN contributed to the study design, instrument development, analyses, and all manuscript drafts. YL, AK, and LP contributed to the instrument development and all manuscript drafts.

The Florida Department of Health provided funding for the study. Dr. Lauren Porter from the Florida Department of Health is a coauthor of the study.

No other financial disclosures were

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