Receptivity to e-cigarette ads among young adults in the US leads to cigarette smoking

Receptivity to advertising for e-cigarettes, cigarettes and cigars were confirmed to be associated with those who would try the respective tobacco product within one year. However, receptivity to e-cigarette advertising also independently increased the odds that 12- to 21-year-olds who have never smoked would try cigarette smoking within the next year by 60 percent. This finding, publishing in the March 26 issue of JAMA Pediatrics, was independent of receptivity to cigarette advertising.

Led by researchers at University of California San Diego Moores Cancer Center and Dartmouth-Hitchcock Norris Cotton Cancer Center, the team analyzed data from the U.S. Population Assessment of Tobacco and Health (PATH) Study and found that 12- to 24-year-olds who have never used tobacco products experienced high recall and/or liking, described as receptivity, of tobacco product advertising (including e-cigarettes). Receptivity was highest for e-cigarette advertising, followed by ads for cigarettes, smokeless tobacco and lastly cigars. Recall and/or liking increased with age, peaking at 69 percent among 18 to 21 year olds.

Receptivity to a particular product's advertising predicted who would try that product within one year, said John P. Pierce, PhD, Professor Emeritus of Cancer Prevention at UC San Diego School of Medicine and Moores Cancer Center.

"This is the most comprehensive assessment to date of young people's receptivity to tobacco industry advertising," said Pierce, the lead author on the study. "There is a growing body of evidence that adolescents who start with an e-cigarette may transition to cigarettes. This study provides the first evidence that e-cigarette advertising is one of the risk factors for those who are underage to become cigarette smokers."

The study collected 959 tobacco advertising images that were used commercially in the year prior to the initial survey and a random sample of 20 of these images (five for each of cigarettes, e-cigarettes, cigars and smokeless tobacco products) were shown to study participants, aged 12 to 24 who reported having never used any type of tobacco product. Participants were considered receptive to a product's advertising if they recalled and/or liked any of the five images for that product. The study included a representative sample of 10,989 never tobacco users in the initial assessment (2013-14) and were interviewed again one year later.

"Recognizing and liking tobacco advertising predicts which lowest risk adolescents will become future consumers of these products, after accounting for a number of traditional risk factors like peer and family smoking," said James Sargent, MD, professor of pediatrics at the Geisel School of Medicine and Norris Cotton Cancer Center at Dartmouth and a lead author. "This suggests that it may be something about the ads, not just the adolescents, which is driving them to try tobacco for the first time."

Young adults at lowest risk of becoming tobacco users were identified from among individuals who reported never using tobacco by their responses to three questions about each product. The questions assessed their curiosity about the product, intention to try it in the near future, and whether they would accept an offer of the product from a best friend. Only those with the strongest rejection to all three questions were categorized as "committed never users." All others were considered susceptible to use. The study confirmed that committed never tobacco users who were receptive to a product's advertising were significantly more likely to try using that product in the following year.

Among 12- to 21-year-old never tobacco users, receptivity to e-cigarette advertising, but not cigarette advertising, at the initial study questionnaire was associated with 4.9 percent of them (an estimated 224,446 never smokers) trying smoking within a year. Only 2.6 percent of those who were not receptive to any advertising tried smoking. This is a significant difference in the odds of starting to smoke cigarettes by 60 percent (i.e. adjusted odds ratio of 1.6). This rate was similar among those who were receptive to cigarette advertising but not e-cigarette advertising. In this group, 5.9 percent tried smoking within one year.

"Years ago, when we took away marketing of Joe Camel and similar ads, we saw a major decline in cigarette use among youth," said Pierce. "Today, these results suggest that it may be possible for the tobacco industry to use e-cigarette advertising as a way around the public health restrictions on cigarette advertising. E-cigarette advertising is allowed on television and we now have evidence that these ads not only are an influence on committed never users to try an e-cigarette, but also an influence on never users under the age of 21 to start smoking cigarettes. There is an urgent need for more research to confirm this finding and determine why e-cigarette advertisements appear so effective at promoting cigarette smoking."