Noticing E-Cigarette Warning Labels in relation to Harm Perceptions and E-cigarette Use Intentions among a National Sample of US Adults
Open Access DepositedElectronic cigarettes (e-cigarettes) entered the US market in 2007 and since then their popularity and use have surged. 1,2 According to the Centers for Disease Control and Prevention (CDC), data from 2022 reveal approximately 11.2% of US adults aged 18 and older currently smoke cigarettes and 5.8% currently use e-cigarettes. 3 Findings from the 2018-2019 Tobacco Use Supplement to the Current Population Survey found that among e-cigarette users, more than 2.21 million were current cigarette smokers (39.1%), more than 2.14 million were former smokers (37.9%), and more than 1.30 million were never smokers (23.1%).4 E-cigarette warning labels (EWLs) represent a key mechanism for communicating harms of product use at the environmental and policy-levels. In 2018, the Food and Drug Administration (FDA) mandated that e-cigarette product packages and advertisements must contain the addictiveness warning statement, “WARNING: This product contains nicotine. Nicotine is an addictive chemical” and the warning must follow size and format requirements for packaging of occupying 30% of the front and back of the principal panels. 5 Research on the effects of e-cigarette warning labels is emerging. Much research conducted to date has been experimental, in controlled settings, or through focus groups. Overall, addiction warning labels may be influential on e-cigarette risk beliefs and willingness to try the product6 and harm and risk perceptions represent key modifiable risk factors associated with e-cigarette use. 7 In this dissertation, adult data from the Population Assessment of Tobacco and Health (PATH) study were analyzed to examine correlates of noticing EWLs and the relationship between noticing EWLs and harm perceptions and e-cigarette use intentions. The first paper analyzed voluntary EWLs prior to the FDA mandate at the cross-sectional level. The second paper examined changes in the odds of noticing EWLs before and after the FDA mandate, along with associated harm perceptions and use intentions, over time. The final paper tested whether 3 separate e-cigarette harm perceptions mediate the relationship between noticing EWLs and use intentions across 3 waves of data. Cross-sectional analyses found that the prevalence of noticing voluntary EWLs in a period prior to the FDA warning label mandate was 22.1%. Current established and experimental electronic nicotine product (ENP) users were significantly more likely to notice EWLs relative to never users. Those who noticed cigarette health warning labels (HWLs) were significantly more likely to notice EWLs relative to those who did not notice cigarette HWLs. Among those who noticed EWLs, there were higher odds of perceiving e-cigarettes to be equally or more harmful than cigarettes. However, there were no associations between noticing EWLs and perceived harm of e-cigarettes, nicotine in e-cigarettes, or e-cigarette use intentions. Longitudinal results found that at Wave 4 (W4) (pre-FDA mandate) 22.3% noticed EWLs. At Wave 5 (W5) (post-FDA mandate), results found that 25.1% noticed EWLs. Compared to W4, there was a significant increase in the odds (aOR=1.13) of noticing EWLs at W5, controlling for covariates of interest, coinciding with the introduction of the newly mandated FDA-warning label. Noticing EWLs was significantly associated with increased perceived harm of e-cigarettes, nicotine in e-cigarettes, and with the perception that e-cigarettes are equally or more harmful than cigarettes, over time. The strength of these associations did not change significantly between waves (i.e., no interaction). Noticing EWLs was not significantly associated with use intentions. Increased perceived harm of e-cigarettes/nicotine decreased intentions to try e-cigarettes among never users. Increased perceived harm of e-cigarettes increased the odds of intention to quit e-cigarettes among current e-cigarettes users. Perceiving e-cigarettes to be equally or more harmful than cigarettes was associated with decreased odds of intention to quit e-cigarettes. Mediation results across Waves 4-6 found that among never ENP users and current established ENP users, noticing EWLs at W4 was not significantly associated with decreased perceived harm of e-cigarettes and nicotine in e-cigarettes at W5. Noticing EWLs was not significantly associated with the relative harm of e-cigarettes among either user group. Moreover, none of the aforementioned harm perceptions were significantly associated with use intentions. There was no significant mediation effect for any of the 3 harm perceptions tested on intentions try e-cigarettes among never ENP users or intention to quit e-cigarettes among current established ENP users. Noticing EWLs did not directly influence e-cigarette use intentions. Overall, the findings of this dissertation indicate warnings on EWLs are being noticed by approximately a quarter of the US population. While noticing voluntary EWLs was less than roughly a quarter prior to the FDA mandate, there was a significant increase in noticing EWLs across two waves of data, which coincided with the FDA mandate. Findings underscore the need for clearer warning statements that articulate the relative harm of e-cigarettes compared to cigarettes. Specific focus should be placed on at risk user groups, for example, whether this misperception deters certain user groups that could benefit from switching to ENPs (e.g., exclusive cigarette users). Insignificant findings from mediation analyses are notable and may suggest the theoretical basis for warnings are not working in the theorized way at the population level. Future surveillance is needed to monitor the FDA mandated warning over a longer period. Research is needed to test possible external factors that could lessen the impact of EWLs, such as exposure to pro-tobacco ads and trust in the federal government. Future research should also seek to understand other constructs of warning label effectiveness, such as psychological reactance to EWLs and warning salience.
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