“I was in a Subway the other day, in line to order a sandwich, and the woman that was standing behind me was Juuling in line … and she was able to do it so discreetly that no one said anything,” said Seth Noar, a professor at UNC-Chapel Hill’s School of Media and Journalism. “I mean can you imagine standing in line at a Subway and someone lighting up a cigarette? That would never happen. People would be like, ‘What are you doing?'”
Noar is co-author on a study published in June in the journal Substance Use & Misuse titled “E-cigarette Outcome Expectancies among Nationally Representative Samples of Adolescents and Young Adults.”
The study’s focus on youth and e-cigarettes comes on the heels of what the FDA called a youth “epidemic” last year.
“If you look at purchasing models, about half of everybody that uses an e-cigarette regularly is under the age of 35,” said Josh Barker, lead author of the study and doctoral candidate at UNC-Chapel Hill’s School of Media and Journalism. The study, however, focused on the two youngest age groups, adolescents (13-17) and young adults (18-25) through nationally representative samples. The authors set out to determine the beliefs underlying youth e-cigarette use — basically, why would young people make the decision to use these products?
The study grouped the survey into both positive and negative outcome expectancies. Positive outcome expectancies included enjoyment, social influences, and advantage over cigarettes. Negative outcome expectancies included health concerns and smoking association. Study authors wrote that the outcome expectancy research “posits that individuals who expect positive outcomes to result from a behavior are more likely to engage in that behavior” with the reverse being true for negative outcomes.
In both age groups, the study found that “expected enjoyment of e-cigarettes — including factors such as taste, stress relief, and doing vape tricks — is a major factor in e-cigarettes’ appeal to adolescents and young adults…”
The study also found that for adolescents, this “enjoyment” factor may be so high it may “essentially cancel out concerns about the health consequences of using e-cigarettes for adolescents.”
“While perceptions of e-cigarette enjoyment were associated with a greater likelihood of use, expectancies of negative health concerns were associated with a lower likelihood that adolescents and young adults had used e-cigarettes,” study authors wrote. “In combined positive/negative models, negative health concerns were only associated with a lower likelihood of young adult ever use, but not for adolescents. This may indicate that beliefs about enjoyment (e.g., flavors, stress relief) essentially cancel out concerns about the health consequences of using e-cigarettes for adolescents. Our findings thus suggest that beliefs about the harms of e-cigarettes likely play a role in their use, and are consistent with prior research that finds individuals with low perceptions of e-cigarette risk to be more likely to use e-cigarettes.”
Barker, whose research focus is in health information, recognized how these results could affect thinking about e-cigarette prevention messaging.
“We might get individuals that are looking to craft messages to where they can point back to this [study], and say ‘Alright, if we’re wanting messages that are salient for both adolescents and young adults, we need to take aim at expected enjoyment. We need to problematize this,'” Barker said. “If people say, ‘This is going to taste good, this is going to make me feel less stressed,’ all this kind of stuff, that’s the stuff you need to directly argue against. You see this in campaigns now.”
Barker pointed to national campaigns, including from the FDA, that focus on naming chemicals in e-cigarettes to highlight health consequences. The Truth Initiative also launched an ad campaign using puppets targeted at youth to share the downsides of e-cigarette use, with the motto, “Safer doesn’t mean safe.” And with more than 20% of high school students using e-cigarettes last year, Barker said there’s some urgency to these campaigns.
“When we talk about anti-vaping messaging, anti e-cigarette messaging, we’re behind,” he said. “We’re six years behind. There [were] social media and television campaigns happening in 2010, 2011. … We’re only starting to crawl towards federally-funded national campaigns about the dangers of e-cigarettes.”
Safety is one angle public health officials can take in messaging, but it comes with its own challenges, even in terms of pinning exactly what is in e-cigarettes. “It varies from batch to batch, it varies from company to company … that uncertainty I think is something that can be emphasized,” said Barker of the ingredients in e-cigarette products and their questionable safety. And Noar said there are some estimates that e-cigarette offerings boast as high as 10,000-15,000 different types of flavors.
“The FDA has the authority to restrict a whole series of things of what e-cigarette companies can do, including product design and what’s in the devices, the liquids, a whole series of things. To my knowledge they have not done that yet,” Noar said.
Noar predicts the FDA may have been more lax with regulation on e-cigarette makers because of their potential to switch smokers using combustible cigarettes — which Noar calls “about the most harmful thing you could do” — to the safer alternative of e-cigarettes. This would only be true, however, if smokers switched completely to e-cigarettes.
“But that can’t come at the expense of this youth problem,” Noar said of any potential public health benefits to smokers. “So there’s a little bit of a balancing act that we have to do, and right now I think we’re out of balance. I think we have too many things that make these things attractive to youth…”
Last year, the FDA did crackdown on e-cigarette manufacturers. In the months after the crackdown, the largest e-cigarette manufacturer, Juul, responded by disabling its Facebook and Instagram accounts and limiting retail sales of certain flavored e-cig pods popular among youth. These flavors would still be available on their site for purchase with age verification.
Of note, the study surveyed youth and adolescents in 2016 — just before the rise of Juul.
“Unfortunately all of that only exacerbated the problem. Between 2017 and 2018 is when we saw the largest increase in youth use of e-cigarettes, mostly attributed to Juul,” Noar said. “So if anything, I think our findings would be even more robust if we re-did the study because Juul is the one that especially has features that are appealing.”
“What Juul has essentially done is sort of develop the sort of perfect product to lure young people to nicotine addiction, and that’s not good for public health. That’s very bad for public health,” Noar added. “Of course there’s enjoyment there because they’ve created this product that is thin and cool and tech-savvy and has amazing flavors, and it’s discreet.”
The flip side of the attraction to youth, Noar said, is that young people don’t associate e-cigarettes with the same harms as cigarettes at all, especially adolescents. Even his own 14-year-old son, he said, “sees vaping as just this different thing.”
“They think it’s either completely harmless or almost entirely harmless. So we need to do a better job communicating with young people about this issue,” Noar said.
Study authors concluded that their data supports “the need for education about potential health hazards of e-cigarettes, which could be achieved through product warnings, tobacco education campaigns, and other interventions for youth.”
“I hope it gets out to people who are health communication and public health people that are focused on e-cigarette use among youth and how we can best reduce it,” said Noar of the study’s results. “Again, the more we understand how young people are thinking about e-cigarettes and what their perceptions are, the better we can not only develop prevention messaging, but develop other policies.”From the Center Out Juuling