Nicotine & Tobacco Research, 2015, 1247–1254 doi:10.1093/ntr/ntu276 Original investigation Advance Access publication December 26, 2014
Original investigation
Knowledge About E-Cigarette Constituents and Regulation: Results From a National Survey of U.S. Young Adults Downloaded from http://ntr.oxfordjournals.org/ at University of Toronto Library on November 16, 2015
Ashley N. Sanders-Jackson PhD1, Andy S. L. Tan MBBS, MBA, MPH, PhD2, Cabral A. Bigman PhD3, Lisa Henriksen PhD1 Stanford Prevention Research Center, School of Medicine, Stanford University, Palo Alto, CA; 2Center of Excellence in Cancer Communication Research, Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA; 3Department of Communication, College of Liberal Arts and Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 1
Corresponding Author: Ashley Sanders-Jackson, PhD, Stanford Prevention Research Center, School of Medicine, Stanford University, 1070 Arastradero Road, Palo Alto, CA 94304, USA. Telephone: 267-515-2523; Fax: 650-723-6450; E-mail: [email protected]
Abstract Objectives: To examine young adults’ knowledge of e-cigarette constituents and regulation and its association with product use and self-reported exposure to marketing. Methods: Young adults (18–34 years, N = 1,247) from a U.S. web panel were surveyed in March 2014. Using multinomial logistic regressions, self-reported exposure to marketing was examined as a predictor of whether participants responded correctly (reference category), incorrectly, or “don’t know” to four knowledge items—whether e-cigarettes contain nicotine, contain toxic chemicals, are regulated by government for safety, and are regulated for use as a cessation aid. Analyses adjusted for demographics and smoking status and were weighted to match the U.S. young adult population. Results: Most respondents did not know if e-cigarettes, contain toxic chemicals (48%), are regulated for safety (61%), and are regulated as cessation aids (68%); fewer than 37% answered all of these items correctly. Current users of e-cigarettes (past 30 days) had a lower likelihood of being incorrect about safety testing (p = .006) and being regulated as a cessation aid (p = .017). Higher exposure to e-cigarette marketing was associated with a lower likelihood of responding “don’t know” than being correct, and with a higher likelihood of being incorrect as opposed to correct about e-cigarettes containing nicotine. Conclusions: Knowledge about e-cigarette constituents and regulation was low among young adults, who are the largest consumer group for these products. Interventions, such as warning labels or information campaigns, may be necessary to educate and correct misinformation about these products.
Introduction Although much research about e-cigarettes has focused on consumer awareness and use of these products,1–4 too little is known about consumer knowledge of e-cigarette constituents and federal regulation. The U.S. Food and Drug Administration (FDA) addresses
concerns about consumer knowledge in its proposed rule to regulate e-cigarettes and other electronic nicotine delivery systems under the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act).5 The proposed rule states: “Many consumers believe that e-cigarettes are ‘safe’ tobacco products or are ‘safer’ than
© The Author 2014. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
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cigarettes. FDA has not made such a determination and conclusive research is not available.”5 Indeed, there is growing evidence that e-cigarettes contain many of the toxic substances contained in traditional combustible cigarettes6 and many also contain nicotine.7 Examples of toxic chemicals contained in e-cigarettes include formaldehyde, acetaldehyde, carbonyls, volatile organic compounds,6 and others (see Pisinger and Dossing8 for a review). Research on public knowledge about e-cigarettes is urgently needed to inform FDA’s policymaking process. False beliefs about product regulation—that is, believing that a product is regulated when it is not—can lead people to infer the products are safer.9–11 Conversely, accurate beliefs about product regulation may be associated with improved understanding of product risks. For example, smokers who responded that FDA does not regulate cigarettes for safety before they are sold to consumers were more knowledgeable than smokers who thought the FDA regulates cigarettes for safety; the former were less likely to endorse myths that milder, low-tar, or additive-free cigarettes were less dangerous.11 E-cigarette marketing is a source of product information for many consumers12 and is increasing rapidly.4,13–16 Previous research has found that exposure to tobacco marketing can result in public misinformation about the risks of tobacco use17,18 and incorrect beliefs.19,20 Consumers may believe that e-cigarettes are safer than cigarettes partly due to the marketing messaging, which make e-cigarettes look more appealing and less harmful than combustible tobacco cigarettes. While print and other mass media advertisements have targeted Whites,21 e-cigarette advertisements also appear on websites that are popular among Blacks and Hispanics16 and at stores located in minority neighborhoods.22 If there is demographic targeting, different demographic groups may diverge in having accurate knowledge about e-cigarettes depending on their level of exposure to e-cigarette marketing. This study aims to examine young adults’ knowledge of e-cigarette constituents and regulation and its association with product use and self-reported exposure to marketing. We further assessed if knowledge differed by demographic characteristics. The study focuses on young adults because this age group has the highest prevalence of experimentation and use of e-cigarettes in the United States.1,4,23 We included nonusers and nonsmokers because their understanding of these products may affect their opinions about regulatory policies, such as regulating marketing or use, and would affect the information available from nonusers and nonsmokers to smokers who are trying to quit.24
participants met inclusion criteria for age and race/ethnicity and the completion rate was 44.7% among eligible participants. This response rate is comparable to those found in Internet surveys of U.S. young adults.25,26 The median time to complete the survey was 13 min and compensation was $10. The study was approved by the Stanford University Institutional Review Board (protocol #25358).
Methods
Tobacco Use
Data Collection
E-cigarette use was categorized as “never user,” “ever user but not in the past 30 days,” and “current user” (any use in the past 30 days). Smoking status was categorized as “nonsmoker (less than 100 cigarettes in their lifetime),” “former smoker (smoked at least 100 cigarettes in their lifetime but none in the past 30 days),” “non-daily smoker,” and “daily smoker” based on the number of days smoked in the past 30 days.
Knowledge items about product constituents were based on prior research.27–31 The two statements were: (a) “Some e-cigarettes contain nicotine” and (b) “E-cigarettes do not contain any of the toxic chemicals that can be found in combustible cigarettes.” Participants were asked to respond true, false, or don’t know. The correct response for the statement about some e-cigarettes containing nicotine was “true” while the correct response for the other item was “false.” In addition, participants were asked to respond to two statements about regulation: (a) “The federal government requires product safety testing for e-cigarettes” and (b) “The federal government regulates e-cigarettes as smoking cessation aids.” The correct response for these two items about e-cigarette regulations was “false.” Responses were coded as correct, incorrect and “don’t know.” Between 1.3% and 2.6% of respondents refused to answer and were coded as “don’t know.” We did not combine incorrect and “don’t know” because those who possess inaccurate information or false beliefs about e-cigarettes may require different types of communication messages than those who possess no information or opinion (“don’t know”).32,33 Both responses suggest the need for some form of communication intervention, but replacing or correcting misinformation may be more difficult than simply informing someone who has not yet received information.34
Self-Reported Exposure to E-Cigarette Marketing Self-reported exposure was measured using four items: “In the past 30 days, how often did you see advertisements for e-cigarettes (a) when you went to a convenience store, liquor store, or gas station, (b) when you used social media such as Facebook, Twitter, or YouTube, (c) when watching television or cable shows, and (d) when reading newspapers or magazines?” Each item was on a four-point scale (don’t know/never [0], once or twice [1], three or four times [2], five or more times [3]). The items were summed in a scale with a singlefactor solution (Cronbach’s alpha = .78; Mean = 1.61, SD = 2.10). Sensitivity analyses using self-reported exposure to e-cigarette marketing variables as separate predictors did not significantly improve model fit (analyses are available on request).
Sociodemographics Variables were age, gender, race/ethnicity (non-Hispanic White, non-Hispanic Black, Other non-Hispanic, and Hispanic), level of education (less than high school, high school, some college, Bachelor’s degree or higher) and household income (
Original investigation
Knowledge About E-Cigarette Constituents and Regulation: Results From a National Survey of U.S. Young Adults Downloaded from http://ntr.oxfordjournals.org/ at University of Toronto Library on November 16, 2015
Ashley N. Sanders-Jackson PhD1, Andy S. L. Tan MBBS, MBA, MPH, PhD2, Cabral A. Bigman PhD3, Lisa Henriksen PhD1 Stanford Prevention Research Center, School of Medicine, Stanford University, Palo Alto, CA; 2Center of Excellence in Cancer Communication Research, Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA; 3Department of Communication, College of Liberal Arts and Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 1
Corresponding Author: Ashley Sanders-Jackson, PhD, Stanford Prevention Research Center, School of Medicine, Stanford University, 1070 Arastradero Road, Palo Alto, CA 94304, USA. Telephone: 267-515-2523; Fax: 650-723-6450; E-mail: [email protected]
Abstract Objectives: To examine young adults’ knowledge of e-cigarette constituents and regulation and its association with product use and self-reported exposure to marketing. Methods: Young adults (18–34 years, N = 1,247) from a U.S. web panel were surveyed in March 2014. Using multinomial logistic regressions, self-reported exposure to marketing was examined as a predictor of whether participants responded correctly (reference category), incorrectly, or “don’t know” to four knowledge items—whether e-cigarettes contain nicotine, contain toxic chemicals, are regulated by government for safety, and are regulated for use as a cessation aid. Analyses adjusted for demographics and smoking status and were weighted to match the U.S. young adult population. Results: Most respondents did not know if e-cigarettes, contain toxic chemicals (48%), are regulated for safety (61%), and are regulated as cessation aids (68%); fewer than 37% answered all of these items correctly. Current users of e-cigarettes (past 30 days) had a lower likelihood of being incorrect about safety testing (p = .006) and being regulated as a cessation aid (p = .017). Higher exposure to e-cigarette marketing was associated with a lower likelihood of responding “don’t know” than being correct, and with a higher likelihood of being incorrect as opposed to correct about e-cigarettes containing nicotine. Conclusions: Knowledge about e-cigarette constituents and regulation was low among young adults, who are the largest consumer group for these products. Interventions, such as warning labels or information campaigns, may be necessary to educate and correct misinformation about these products.
Introduction Although much research about e-cigarettes has focused on consumer awareness and use of these products,1–4 too little is known about consumer knowledge of e-cigarette constituents and federal regulation. The U.S. Food and Drug Administration (FDA) addresses
concerns about consumer knowledge in its proposed rule to regulate e-cigarettes and other electronic nicotine delivery systems under the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act).5 The proposed rule states: “Many consumers believe that e-cigarettes are ‘safe’ tobacco products or are ‘safer’ than
© The Author 2014. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: [email protected].
1247
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cigarettes. FDA has not made such a determination and conclusive research is not available.”5 Indeed, there is growing evidence that e-cigarettes contain many of the toxic substances contained in traditional combustible cigarettes6 and many also contain nicotine.7 Examples of toxic chemicals contained in e-cigarettes include formaldehyde, acetaldehyde, carbonyls, volatile organic compounds,6 and others (see Pisinger and Dossing8 for a review). Research on public knowledge about e-cigarettes is urgently needed to inform FDA’s policymaking process. False beliefs about product regulation—that is, believing that a product is regulated when it is not—can lead people to infer the products are safer.9–11 Conversely, accurate beliefs about product regulation may be associated with improved understanding of product risks. For example, smokers who responded that FDA does not regulate cigarettes for safety before they are sold to consumers were more knowledgeable than smokers who thought the FDA regulates cigarettes for safety; the former were less likely to endorse myths that milder, low-tar, or additive-free cigarettes were less dangerous.11 E-cigarette marketing is a source of product information for many consumers12 and is increasing rapidly.4,13–16 Previous research has found that exposure to tobacco marketing can result in public misinformation about the risks of tobacco use17,18 and incorrect beliefs.19,20 Consumers may believe that e-cigarettes are safer than cigarettes partly due to the marketing messaging, which make e-cigarettes look more appealing and less harmful than combustible tobacco cigarettes. While print and other mass media advertisements have targeted Whites,21 e-cigarette advertisements also appear on websites that are popular among Blacks and Hispanics16 and at stores located in minority neighborhoods.22 If there is demographic targeting, different demographic groups may diverge in having accurate knowledge about e-cigarettes depending on their level of exposure to e-cigarette marketing. This study aims to examine young adults’ knowledge of e-cigarette constituents and regulation and its association with product use and self-reported exposure to marketing. We further assessed if knowledge differed by demographic characteristics. The study focuses on young adults because this age group has the highest prevalence of experimentation and use of e-cigarettes in the United States.1,4,23 We included nonusers and nonsmokers because their understanding of these products may affect their opinions about regulatory policies, such as regulating marketing or use, and would affect the information available from nonusers and nonsmokers to smokers who are trying to quit.24
participants met inclusion criteria for age and race/ethnicity and the completion rate was 44.7% among eligible participants. This response rate is comparable to those found in Internet surveys of U.S. young adults.25,26 The median time to complete the survey was 13 min and compensation was $10. The study was approved by the Stanford University Institutional Review Board (protocol #25358).
Methods
Tobacco Use
Data Collection
E-cigarette use was categorized as “never user,” “ever user but not in the past 30 days,” and “current user” (any use in the past 30 days). Smoking status was categorized as “nonsmoker (less than 100 cigarettes in their lifetime),” “former smoker (smoked at least 100 cigarettes in their lifetime but none in the past 30 days),” “non-daily smoker,” and “daily smoker” based on the number of days smoked in the past 30 days.
Knowledge items about product constituents were based on prior research.27–31 The two statements were: (a) “Some e-cigarettes contain nicotine” and (b) “E-cigarettes do not contain any of the toxic chemicals that can be found in combustible cigarettes.” Participants were asked to respond true, false, or don’t know. The correct response for the statement about some e-cigarettes containing nicotine was “true” while the correct response for the other item was “false.” In addition, participants were asked to respond to two statements about regulation: (a) “The federal government requires product safety testing for e-cigarettes” and (b) “The federal government regulates e-cigarettes as smoking cessation aids.” The correct response for these two items about e-cigarette regulations was “false.” Responses were coded as correct, incorrect and “don’t know.” Between 1.3% and 2.6% of respondents refused to answer and were coded as “don’t know.” We did not combine incorrect and “don’t know” because those who possess inaccurate information or false beliefs about e-cigarettes may require different types of communication messages than those who possess no information or opinion (“don’t know”).32,33 Both responses suggest the need for some form of communication intervention, but replacing or correcting misinformation may be more difficult than simply informing someone who has not yet received information.34
Self-Reported Exposure to E-Cigarette Marketing Self-reported exposure was measured using four items: “In the past 30 days, how often did you see advertisements for e-cigarettes (a) when you went to a convenience store, liquor store, or gas station, (b) when you used social media such as Facebook, Twitter, or YouTube, (c) when watching television or cable shows, and (d) when reading newspapers or magazines?” Each item was on a four-point scale (don’t know/never [0], once or twice [1], three or four times [2], five or more times [3]). The items were summed in a scale with a singlefactor solution (Cronbach’s alpha = .78; Mean = 1.61, SD = 2.10). Sensitivity analyses using self-reported exposure to e-cigarette marketing variables as separate predictors did not significantly improve model fit (analyses are available on request).
Sociodemographics Variables were age, gender, race/ethnicity (non-Hispanic White, non-Hispanic Black, Other non-Hispanic, and Hispanic), level of education (less than high school, high school, some college, Bachelor’s degree or higher) and household income (
