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Impact of e-cigarette health warnings on motivation to vape and smoke
  1. Noel T Brewer1,2,
  2. Michelle Jeong3,
  3. Marissa G Hall1,2,
  4. Sabeeh A Baig1,4,
  5. Jennifer R Mendel2,
  6. Allison J Lazard2,5,
  7. Seth M Noar2,5,
  8. Madeline R Kameny1,
  9. Kurt M Ribisl1,2
  1. 1 Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
  2. 2 Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
  3. 3 Center for Tobacco Studies, Rutgers School of Public Health, New Brunswick, New Jersey, USA
  4. 4 Department of Sociomedical Science, Columbia University Mailman School of Public Health, New York, New York, USA
  5. 5 School of Media and Journalism, University of North Carolina, Chapel Hill, North Carolina, USA
  1. Correspondence to Dr Noel T Brewer, Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA; ntb{at}


Background A prevailing hypothesis is that health warnings for electronic cigarettes (e-cigarettes) could drive people away from vaping and towards smoking cigarettes. We consider an alternative hypothesis that e-cigarette warnings discourage both vaping and smoking.

Methods Participants were a national convenience sample of 2218 US adults who used e-cigarettes, cigarettes or both. In August 2018, we randomised participants to one of three warning types (control text about littering, text-only e-cigarette warning or pictorial e-cigarette warning). We further randomised participants viewing e-cigarette warnings to one of three topics (nicotine addiction, health hazards of use, or both health hazards and harms of use). The preregistered primary outcome was intentions to quit vaping among e-cigarette users. Secondary outcomes included interest in smoking and Tobacco Warnings Model constructs: attention, negative affect, anticipated social interactions and cognitive elaboration.

Results Text warnings elicited higher intentions to quit vaping than control among e-cigarette users (d=0.44, p<0.001), and pictorial warnings elicited still higher intentions to quit vaping than text (d=0.12, p<0.05). Text warnings elicited lower interest in smoking compared with control among smokers (p<0.05); warnings had no other effects on interest in smoking among smokers or non-smokers. Text warnings about health hazards elicited higher intentions to quit vaping than nicotine addiction warnings. E-cigarette warnings also increased Tobacco Warnings Model constructs.

Discussion E-cigarette health warnings may motivate users to quit vaping and discourage smoking. The most promising warnings include health hazards (other than nicotine addiction) and imagery. We found no support for the hypothesis that e-cigarette warnings could encourage smoking cigarettes.

  • electronic nicotine delivery devices
  • addiction
  • nicotine
  • packaging and labelling
  • prevention

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  • Contributors NTB had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: NTB, MJ, MGH, SAB, JRM, AJL, SMN, MTK, KMR. Acquisition, analysis or interpretation of data: NTB, SAB. Drafting of the manuscript: NTB, MJ, MGH, JRM, SAB. Critical revision of the manuscript for important intellectual content: NTB, MJ, MGH, SAB, JRM, AJL, SMN, MTK, KMR. Statistical analysis: NTB, SAB. Obtained funding: NTB, KMR. Administrative, technical or material support: NTB, JRM. Study supervision: NTB, JRM.

  • Funding Research reported in this publication was supported by grant number P50CA180907 from the National Cancer Institute and FDA Center for Tobacco Products (CTP). T32-CA057726 from the National Cancer Institute of the National Institutes of Health supported Marissa Hall’s time writing the paper.

  • Disclaimer The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration. The funding institutions had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

  • Competing interests None of the authors have received funding from tobacco product manufacturers. NTB and KMR have served as paid expert consultants in litigation against tobacco companies. The other authors declare no conflicts of interest.

  • Patient consent for publication Not required.

  • Ethics approval The University of North Carolina institutional review board approved this study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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