Background

Electronic nicotine delivery devices (ENDS) are battery-powered electronic devices that deliver nicotine in the form of heated vapour. ENDS encompass a variety of products with different shapes and sizes: while many small-sized ENDS look and feel like regular cigarettes, there are also medium-sized pen-style ENDS, popularly referred as ‘e-hookahs’ or ‘vape pens’, and large tank-size ENDS known as ‘advanced personal vaporisers (APVs)’, or ‘Mods’. ENDS first appeared in China in 2004 and were introduced into the US market in 2007.1

Commonly called ‘e-cigarettes’, ENDS have rapidly emerged into public consciousness. E-cigarette marketing appears across various media channels, notably including television and billboards—on which tobacco advertising has been prohibited since 1971 and 1998, respectively. While less than 5 years ago these products were scarcely known among the US populace,2–4 today television and radio ads for e-cigarettes feature catchy slogans and endorsements by celebrities and local radio personalities across the USA.5 Cab-top and bus displays, sports sponsorships, contests and giveaways—all illegal or highly regulated media platforms for cigarette promotion—supplement e-cigarettes’ substantial presence in print and online.6 ,7

There is evidence that rates of e-cigarette use and awareness also are increasing rapidly. In 2010, two surveys of American adults found overall that 40.2% of respondents had heard of e-cigarettes and that 11.4% of smokers, 2% of former smokers and 0.8% of never smokers had tried the products.8 In 2010–2011, 73% of US adult respondents (N=1520) to the International Tobacco Control Four-Country Study reported they had heard of e-cigarettes, 14.9% had tried e-cigarettes and 6% were current users.9 In 2013, the CDC reported National Youth Tobacco Survey data indicating that experimentation and use of e-cigarettes doubled among middle and high school students from 2011 to 2012. As of 2012, this increase represented an estimated 1.78 million students who have used the products.10 In the largest study yet to examine e-cigarette use in the USA, our research team conducted an online survey with a nationally representative sample of American adults in which 86% of respondents reported being aware of e-cigarettes and 15% said they had tried them.11 Our results also indicated variance in e-cigarette use based on demographics; higher rates of use were reported among whites, young adults, those at higher income levels and/or members of the lesbian, gay and bisexual (LGB) communities. The differential appeal of e-cigarettes indicated by these use patterns suggests that product marketing may specifically target certain demographic groups. Yet little is known about how different groups encounter and interact with information about e-cigarettes. Research is needed to inform the public health community about the media platforms across which e-cigarette information is consumed.

This paper describes patterns of exposure to, searching for and sharing of information about e-cigarettes among a nationally representative sample of US adults.

Conclusions and discussion

While a few studies have assessed overall awareness about e-cigarettes,8 ,14 this is the first to characterise levels of exposure to, searching for and sharing of e-cigarette-related information across media and other communications channels. The results of this research indicate high levels of awareness; 86% of the sample was aware of e-cigarettes and nearly half (47%) had heard about them via media channels, significant findings given how recently these products have entered the market and the fact that less than 20% of the US population was aware of them 5 years ago.15 Passive exposure to e-cigarette messaging was more likely among tobacco users, young adults, males, those with education beyond high school and those who use social media and spend more time online.

Television represented the most common medium through which people reported being exposed to e-cigarette information. Our survey did not measure the source or valence of televised e-cigarette information; nonetheless, this finding may have implications for e-cigarette marketing regulation. While we cannot directly predict the effects of a television e-cigarette advertising ban, studies of combustible tobacco indicate that such bans are associated with reduced use of the products.16 Lessons learned from the Master Settlement Agreement suggest that e-cigarette manufacturers may simply circumvent a ban on televised ads by increasingly promoting their products through event sponsorship, social media and product websites.17 A recent congressional investigation demonstrated that such e-cigarette promotions already are being used to target US youth.18 Our finding that e-cigarette users are more likely to be exposed to e-cigarette information through channels prone to individually targeted marketing, such as TV viewing sites, Twitter, Facebook, YouTube, email and internet search engines, also suggest targeted marketing towards e-cigarette users via non-traditional media channels.

Although a relatively small proportion of our sample reported having searched for (∼5%) or shared (∼2%) e-cigarette-related information across various communications channels, e-cigarettes are a relatively new phenomenon, and product marketing has increased dramatically since this survey was fielded.19 To add perspective to these findings, Fox and Duggan20 reported in 2013 that, in the past 12 months, 16% of internet users had searched for others sharing a health concern, and 8% had posted a health-related question or shared personal health experiences—behaviours likely more expected from the general population than searching for or sharing e-cigarette information.

While a few studies have confirmed potential exposure to internet information related to e-cigarettes,21 ,22 this is the first paper to examine search for and sharing of e-cigarette information online. Our results uncovered important demographic differences in searching and sharing behaviour. Current tobacco use was positively and significantly associated with likelihood of searching for e-cigarette information, not surprising given that the products may be perceived as smoking cessation aids. Also not surprising are our findings that e-cigarette users were more likely than non-users to search for e-cigarette information on Facebook, and more likely than non-users to share such information via word of mouth and Facebook. Whereas age had an apparent inverse relationship with search activity, it was difficult to separate differences explained by age from those explained by education level without further interaction analyses. Our results indicating that Latinos and self-identified LGB were more likely than other demographic groups to share e-cigarette information, even after controlling for income, time spent online and use of social media, warrant further research to uncover the mechanisms behind higher levels of e-cigarette information sharing among these populations.

Not surprisingly, more time spent using the internet and presence on social media networks increased one's likelihood of searching for and sharing e-cigarette information. Perhaps once people reach a certain threshold of passive exposure to information about a product, perception of its popularity prompts them to begin actively searching for and sharing information about the product. Although this question cannot be answered using the cross-sectional analysis reported here, the Wave 2 follow-up survey will provide opportunity to test the theory using longitudinal data.

Marketing and promotion of e-cigarettes, not only via traditional media channels but also online1 and across social media,19 has likely contributed significantly to the rapid rise in awareness and popularity of the products. Our work recently identified exponential growth in e-cigarette promotional spending over the past 3 years, with expenditures for the first two quarters of 2013 already double the amount spent during all of 2012.23 The current analysis represents an important step towards understanding how e-cigarette-related information may reach various audiences and audience characteristics that make such information more likely to be shared. In addition to product marketing efforts to target specific demographics, inherent product qualities may make e-cigarettes more appealing to certain groups (ie, technological novelty). Some demographic groups may be more enthusiastic adopters of new technology and more likely to spread product information to their social networks. Further research should examine product characteristics associated with higher rates of uptake among specific groups.

This study is limited first by its cross-sectional design, which does not allow characterisation of trends or behaviour changes over time. Second, the data represent self-report with no objective validation measures. Third, this study did not assess the content of e-cigarette information searched for or shared by respondents; content analysis may be an important component of future studies. Fourth, our findings indicate low prevalence of searching and sharing e-cigarette information; however, the expected frequency of searching for or sharing any given topic on a specific day is likely to be low.

The findings from our study have implications for regulatory and public health policy surrounding e-cigarettes. Clearly, US adults are being exposed to e-cigarette marketing on the internet and in social media networks. Current tobacco users are more likely to search for e-cigarette-related information, suggesting that they may perceive the products as viable cessation aids, a practical alternative to combustible cigarettes in settings where smoking is banned or a way to mitigate the harm of ongoing tobacco use. Exposure to, searching for and sharing of e-cigarette information differs by demographics, possibly indicating that marketing differentially targets specific population groups. Further research should explore how subpopulations encounter and share information about e-cigarettes and how those behaviours relate to subsequent use of either e-cigarettes or combustible tobacco. Examining the inter-relationships between exposure to, searching for and sharing e-cigarette information using longitudinal data may illuminate where the communication cycle begins and whether that cycle is different for e-cigarettes than for regular cigarettes.