Searching for Anti-Vaping Public Health Messaging That Works

The meteoric rise in youth e-cigarette use has public health experts scrambling to find a way to convince teenagers to stop vaping, but despite known risks, limited data on the long-term effects of vaping has made their job challenging.

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Trying to Stem the Tide of Youth Vaping: Searching for Public Health Messaging that Works

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By Katherine Corley
Population Health Scholar
University of Texas System
Dual Degree Master's Student in Journalism and Global Policy
UT Austin Moody College of Communication & UT Austin LBJ School of Public Affairs

Today’s teenagers are smoking fewer old school cigarettes than ever before. Unfortunately, that decline is being outpaced by the rapid rise of e-cigarette use, or vaping, among teens. E-cigarette use from 2017 to 2018 surged by 78% among high schoolers and by 48% among middle school students, according to a recent analysis of data from the 2011–2018 National Youth Tobacco Survey (NYTS)

Due to this rise in vaping, overall tobacco product use jumped by 38% among high school students and by 29% among middle schoolers between 2017 and 2018.

This matters because youth tobacco users often grow up to be addicted adults, as the developing brains of teenagers are more vulnerable to nicotine addiction than adult brains.  Over 80% of adult smokers start smoking by age 18, and nearly 100% of adult smokers began tobacco use by age 26, according to a report by the Surgeon General.  Additionally, youth who start out using e-cigarettes are more likely to progress to smoking traditional cigarettes

Reversing the viral spread of youth e-cigarette use will require an arsenal of tactics similar to what ultimately led to the decline in use of traditional cigarettes. Such tactics could include paid media campaigns, new FDA regulations, and national and state policies like tax increases on tobacco products and the creation of smoke-free zones.

“It’s a new battle, but in many ways the same war, with many of the same opponents” said Eric Solberg, Vice President of Academic and Research Affairs for UT Health Science Center at Houston.  “The major cigarette companies have either acquired e-cigarette and vaping companies or are acting in concert with them to oppose any regulation. They have made it difficult in the past to advance effective public health strategies, and are likely to do so again.”

One challenge in crafting effective strategies to discourage e-cigarette use, said Solberg, involves understanding some of the new ways that adolescents and teenagers learn about, acquire, and use tobacco products. In addition to the themes that have long been used to market tobacco – “sex, independence, and rebellion,” according to the CDC – e-cigarettes are also being promoted as safer than traditional cigarettes. And such marketing is working. Research consistently shows that youth commonly perceive e-cigarettes as safer and less addictive than traditional cigarettes.  In a recent study, 27% of e-cigarette smokers (ages 12-21) did not even know that the products they were using contained nicotine, a highly addictive stimulant. Most teens report that they started using e-cigarettes because of the fun flavors, a desire to do ‘smoke tricks,’ and easy access to e-cigs through friends or family who vape.

Social media, in particular, has been a powerful platform for shaping teen perceptions of e-cigarette use. One recent study using data from Twitter found that user tweets and commercial tweets promoting e-cigarettes had a much larger audience reach than user tweets opposing e-cigarettes that often contained some type of educational information. 

It’s a new battle, but in many ways the same war, with many of the same opponents. -Eric Solberg, Vice President of Academic and Research Affairs for UT Health Science Center at Houston.

“Initially, Juul used social media posts featuring young people and bright colors to get the word out about their product, and it skyrocketed,” said Keryn Pasch, Associate Professor in the Department of Kinesiology and Health Education at UT Austin.  “Additionally, user-generated content about e-cigarettes and vaping has a huge presence on social media, such as popular ‘vape trick’ videos of people creating unique visuals with exhaled e-cig smoke.”

Point-of-sale marketing of e-cigarettes at convenience stores also appeals to youth, said Eric Solberg.

“Young people often shop at convenience stores, and when they are purchasing their bottle of Gatorade or another product, they are hit with point-of-sale e-cigarette displays at the check-out counter,” Solberg said. “The e-cig industry, especially Juul, is reinforcing their messaging a couple of times a day through various outlets, even when you are simply buying chips at a gas station and see a rack of Juul e-cigarettes at the register.”

In 2018, the FDA began investigating the marketing and retail practices of Juul and other e-cigarette companies as part of a series of actions to reduce the epidemic of underage vaping. A Stanford research group found that Juul’s advertisements were clearly targeting youth, despite the company’s assertion that their products were for adults only.

Advocates of vaping assert that e-cigarettes are safer than traditional cigarettes and can help cigarette smokers quit. However, Steve Kelder, Associate Regional Dean of the UT School of Public Health campus in Austin, emphasizes that vaping is not a harmless activity, even if better than cigarettes.

 “If someone is a heavily addicted smoker, let’s say a pack to three or four packs of cigarettes a day, I would definitely recommend that they take up vaping as an alternative, because vaping is safer.  But it’s not safe. And that’s the message that gets garbled sometimes,” said Kelder, also a Professor in the Division of Epidemiology, Human Genetics and Environmental Sciences at the UT School of Public Health.

For instance, research has shown that nicotine intake harms adolescent brains. Exposure to nicotine at a young age can cause lasting deficits in learning, mood, attention, and impulse control.  Competition between e-cigarette manufacturers has led to higher and higher nicotine concentrations in e-cigarette liquid, all available in appealingly sweet flavors. Juul, a prominent e-cig manufacturer partially owned by the tobacco giant Altria, claims on their website that one 5% strength e-cigarette pod is equivalent to the nicotine content of 20 cigarettes.  Recently, the FDA announced an uptick in brain seizures—a known side effect of nicotine toxicity—in young adults using e-cigarettes.

“There’s no good reason for kids to intake nicotine—like none—other than [a company] wants to addict them and have a customer for the rest of their lives,” Kelder said.

Since e-cigarettes are relative newcomers to the marketplace, information on the long-term health impacts of vaping is simply not yet available.  However, research has shown that number of the chemicals in e-cigarette vapor are known carcinogens.  The vapor also contains metals and chemical components that can cause cell and tissue dysfunction and DNA damage.

“We don’t have information on people who have been vaping for 30 years—there’s just a time problem,” said Michael Mackert, Director of the Center for Health Communications at UT’s Dell Medical School. “But what we can see of the health impacts doesn’t look good.  And it’s unlikely to look good 20 years from now.”

The FDA has extended its successful anti-smoking campaign, "The Real Cost," to vaping.

In an effort to counter the epidemic of youth vaping, the FDA recently expanded its anti-tobacco campaign, “The Real Cost,” to e-cigarettes, focusing on convincing youth of the health risks of vaping. This strategy is based on prior anti-smoking campaigns, such as Tips from Former Smokers, that featured graphic imagery of the health consequences of cigarettes intended to scare teens into quitting. The FDA is conducting research on the effectiveness of its anti-vaping campaign, but no results are available yet.

However, because youth don’t think e-cigarettes are bad for them like traditional cigarettes, several public health experts suggest that anti-vaping ads should instead target teenagers’ natural sense of rebellion, pitting them against a tobacco industry that is trying to manipulate them into getting hooked on vaping.

“A health problem that could happen in 20 or 30 years feels like an eternity to young people.  So instead of using the message, ‘Don’t die of cancer,’ we say, ‘Don’t be a tool of Big Tobacco.’ And that message worked really well,” Mackert said.

One prominent example of this type of messaging is the Truth Campaign, an anti-tobacco website that uses edgy graphics alongside strong language urging teens to come together to “expose Big Tobacco’s lies.”

However, because public health campaigns that specifically target vaping are still rare and new, little research about their effectiveness exists. 

“We don’t know of any successful anti-vaping campaigns yet because we don’t have enough data,” Kelder said.  “Right now we’re just throwing spaghetti at the wall to see what sticks.”

In the long run, said Solberg, what matters as much as the message will be the extent and intensity of public health campaigns focused  on reducing e-cigarette use.

“We need to put our money where our mouth is,” he said. “We need to compete for the brains of young people through paid mass media counter-advertising.”