New Tobacconomics research explores the effect of voluntary health warning messages in magazine ads on the perceived harmfulness of ENDS
With the rising popularity of electronic nicotine delivery systems (ENDS) in the United States, the relative and absolute harms of ENDS use have become a subject of heated debate in the public health community. From a continuum of risks perspective, ENDS are substantially less harmful than cigarettes, potentially reducing health risks to those who substitute ENDS for smoking cigarettes. However, the long-term effects of ENDS and their overall public health impact remain unclear.
A new study by Tobacconomics researchers Ce Shang, Jidong Huang, Kai-Wen Cheng, and Frank Chaloupka, “The Association between Potential Exposure to Magazine Ads with Voluntary Health Warnings and the Perceived Harmfulness of Electronic Nicotine Delivery Systems (ENDS)”, published last month in the International Journal of Environmental Research and Public Health, explores the link between voluntary health warning messages in magazines on perceived harmfulness of ENDS.
Health warnings are considered to be an effective method to inform consumers about the risks of smoking, and thereby reduce cigarette consumption. With the increasing use of ENDS, how health warning messages for ENDS are framed and conveyed to consumers is critically important, because it may impact the harm perceptions and relative use of ENDS and cigarettes that eventually affect public health.
In May 2016, the U.S. Food and Drug Administration (FDA) issued a deeming rule that expands its regulatory authority to ENDS. By August 2018, the rule will require all ENDS advertisements and packages to carry the warning statement, “WARNING: This product contains nicotine. Nicotine is an addictive chemical”. This statement is required to occupy at least 20% of an advertisement (30% of the principal display panels of the package) and appear in at least 12-point font size. Some ENDS and e-liquid products had already carried voluntary warnings in their advertisements or on product packaging prior to issuance of this rule.
The study’s lead author, Dr. Ce Shang, together with her co-investigators found that higher exposure to ENDS magazine ads with warnings was associated with a lower probability that non-smokers considered ENDS to be equally or more harmful compared to cigarettes. By contrast, this pattern was not found among smokers.
Several scenarios may explain this finding. First, given that the researchers could not distinguish exposure to ENDS ads with warnings from exposure to warnings, it is likely the estimated association captured the effects of magazine ads rather than warnings. Second, it is possible that the ads with warnings appear more trustworthy for nonsmokers; thus, they mediate the effects of ads instead of the effects of warnings themselves. Third, it is also possible that nonsmokers are more likely than smokers to have misperceptions of ENDS relative harmfulness, and are less likely to believe its potential benefits for smokers.
In addition, the study found that minority non-smokers were more likely to perceive ENDS to be equally or more harmful than cigarettes. This finding highlights that the misperception about relative harms is among Black and Hispanic populations than the White population, which may further exacerbate the existing racial/ethnic disparity in smoking and related harms.
Moreover, the analysis on gender patterns suggests that, although gender does not play a significant role in smokers’ risk perceptions, female nonsmokers were more likely to perceive ENDS to be equally or more harmful compared to cigarettes. This misperception potentially results from nicotine poisoning of children or voluntary warning messages about the potential harms of nicotine to pregnant women.
The paper shows that there was insufficient evidence found to prove the association between exposure to ENDS magazine ads with existing health warnings and perceived relative harms of ENDS to cigarettes. However, the FDA regulation discussed above may have an impact on risk perceptions in the future. Furthermore, considering the rise in ENDS advertising, more research is needed to determine the effect of these health warnings on consumer behavior.