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Abstract
Introduction Flavoured e-liquids are especially appealing to young adults. The objective of the present study was to evaluate the effects of text warning labels (WLs) on e-liquid vials used in flavoured electronic cigarettes (e-cigarettes) on e-cigarette non-users’ perceptions of harm, addictiveness, emotional valence, interest in trying e-cigarettes and visual attention.
Methods Young adults aged 18–25 years (n=313) who were non-e-cigarette users were recruited online and randomised to view images of one of two e-liquid vial conditions (with text WL or without text WL). Each participant was exposed to four images of e-liquid vials. After observing each image, participants reported interest in trying e-cigarettes, emotional valence, perceived harm and addictiveness. Additionally, participants completed an assessment of self-reported visual attention with a priori regions of interest (e-liquid branding and text WL).
Results Separate two-way Analysis of Variance(ANOVA) that examined the main effects of sex and warning were used for each measure. Text WL on e-liquid vials decreased young adults’ intention to use e-cigarettes (especially in men), increased harm perception and decreased appeal to the product. However, they did not influence the perceived addictiveness of e-cigarettes and rarely grabbed attention. Men perceived e-cigarettes as less harmful and less addictive.
Conclusions The results suggest that text WLs on e-liquid vials are moderately effective in preventing e-cigarette use in young adults. However, they capture less attention than the rest of the vial and fail to increase the perception of addictiveness. It is suggested to explore other types of design to increase the effectiveness of WLs.
- electronic nicotine delivery devices
- packaging and labelling
- prevention
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Introduction
Electronic cigarettes (e-cigarettes) are battery-powered devices that deliver vapour which may be inhaled in the same way as tobacco is smoked. Nowadays, advanced personal vaporisers (APVs) are more popular among adolescents and young adults than first-generation e-cigarettes (77% of e-cigarette users use APVs).1 APVs have refillable tanks where a liquid (e-liquid) can be added by the user, and the vapour is released when the e-liquid is heated. This offers users the opportunity for customisation of nicotine levels and flavours.
Different studies have found that flavoured e-cigarettes are especially appealing to young adults, and adolescents have reported flavours as a motivation for e-cigarette use.2 3 Gender differences have been found when evaluating the reasons for initiation and outcome expectancies regarding e-cigarettes. Men reported more positive expectancies about e-cigarettes (eg, taste, social facilitation), whereas women rated e-cigarettes higher for weight control. Men also reported greater addiction expectancy than women.4
E-cigarettes can potentially elicit nicotine addiction and the vaping devices may contain other harmful substances.5 To warn users (and potential users) of the risks of using e-cigarettes, at least 14 countries have already required that e-cigarettes bear health warning labels (WLs).6 Experimental studies have shown that exposure to e-cigarette WLs led to increased harm and addictiveness perceptions and decreased usage intentions in smokers, e-cigarette users7 and young non-smokers.8
However, research in this field has been done mainly with WLs located on product ads and product packaging. Few studies have evaluated the effect of WLs on flavoured e-liquid vials. Flavours are one of the main sources of motivation for e-cigarette use in adolescents and young adults,2 3 and flavoured e-liquid vials are used massively in marketing on social media (eg, Instagram).9 A recent study done with fMRI and eye tracking found that e-liquid ads increase the nucleus accumbens’ activity and interfere with recall and attention to WLs.10
Nonetheless, there is little information on the impact of WLs on e-liquid vials on other measures (eg, harm perception or intention to use e-cigarette). Additionally, research in this field is scarce in low/middle-income countries (LMICs), which makes it difficult to adopt a public health policy for mandatory WLs on e-cigarettes. In fact, no LMIC has regulated the use of WLs on e-cigarettes.6 This study aimed to investigate the effects of WLs on e-liquid vials on young adults’ (non-users of e-cigarettes) perceptions of harm, addictiveness, emotional valence, interest in trying e-cigarettes and visual attention. The study was conducted in an LMIC (ie, Colombia).
Methods
Participants
The sample was recruited through students’ high school and university mailing lists, and through Facebook postings, where a short description of the study was included. Based on the average age onset of e-cigarette use in Colombia (23.2 years),11 we selected young adult non-smokers between 18 and 25 years of age who did not use and had not tried e-cigarettes. A sample of 313 subjects (52.1% female), with a mean age of 20.05 years (SD=1.92) participated in the study.
The sample was divided randomly into two conditions: images of sweet/fruit flavoured e-liquid vials with text WL (n=155) and images of sweet/fruit flavoured e-liquid vials without text WL (n=158). Online supplemental table S1 summarises the basic demographic characteristics of the sample. All the participants provided written informed consent to participate in the study.
Supplemental material
Stimuli
We selected four images of e-liquid vials. Images were taken from the internet and social media (see online supplemental table S2). E-liquids were for sweet (ie, candy/desserts) and fruit flavours, based on evidence of the appeal of these flavours to young adults compared with others flavors.3 The text WL was a translation to Spanish of the current Food and Drug Administration (FDA) e-cigarette warning about nicotine addiction: ‘WARNING: This product contains nicotine. Nicotine is an addictive chemical’.12 The study was conducted online using Qualtrics survey software.
Supplemental material
Measures
Based on previous studies, participants rated each of the four flavoured e-liquid vials (with and without text WL), on their interest in trying e-cigarettes (‘How much does this image make you want to try e-cigarettes?’),13 affective valence (‘When you see this image, do you feel a pleasant or unpleasant sensation?’),14 perceived addictiveness (‘After seeing this image, how addictive do you think e-cigarettes are?’) and harm perception (‘After seeing this image, how harmful for your health do you think e-cigarettes are?’).15 All attributes were rated on Visual Analogue Scales from 1 to 10. Participants in the WL group viewed the e-liquid images again and were asked to ‘click’ once on the portion of the image that most grabbed their attention (participants could only click on the image once). Participants’ clicks enabled preparation of ‘heat maps’ that generated hot spots of varying intensities, reflecting the location of the click. Similar to previous research, two a priori regions of interest (ROIs) were defined (ie, branding content and text WL).16 Branding ROIs included brand names or slogans, and product depictions. The text WL ROI was constructed around the warning label text box.
Statistical analysis
Interest in trying e-cigarettes, affective valence, perceived addictiveness and harm perception were analysed using two-way ANOVAs with the main effects of sex and warning (with/without) (average score from the four images was used for this analysis). Visual attention was analysed using 2×2 mixed ANOVA, with sex as the between-subject factor and region (branding content and WL) as the within-subject factor (for this analysis, the percentage of elections for each ROI was obtained). Post hoc analyses were performed using Bonferroni correction. All statistical analyses were performed using SPSS V.20.0 software.
Results
Interest in trying e-cigarettes
The ANOVA revealed a significant main effect of warning (F1309=34.11, p<0.001, ηp 2=0.09). Text WLs on e-liquid vials decreased interest in trying e-cigarettes (Mwith WL=2.11, SE=0.17, Mwithout WL=3.55, SE=0.17, p<0.001, d=0.61) (figure 1A). However, as indicated by the warning×sex interaction (F1309=25.42, p<0.001, ηp 2=0.07), text WLs had a greater effect (ie, more decrease interest) in men (Mwith WL=1.29, SE=0.25, Mwithout WL=3.97, SE=0.24, p<0.001, d=1.33) than in women (p=0.56).
(A) Differences between e-liquid vials with and without text WLs. *P<0.05. Bars indicate ±1 SEM. WL: warning label. (B) Example of heat map for e-liquid vials with text WL. e-cigarettes, electronic cigarettes; WL, warning label.
Valence
The ANOVA yielded a significant main effect of warning (F1309=15.07, p<0.001, ηp 2=0.04). Text WLs on e-liquid vials decreased positive valence towards e-cigarettes (M with WL=4.82, SE=0.15, Mwithout WL=5.65, SE=0.15, p<0.001, d=0.43) (figure 1A).
Perceived addictiveness of e-cigarettes
The ANOVA revealed a significant main effect of sex (F1309=17.91, p<0.001, ηp 2=0.05). Men perceived flavoured e-cigarettes as less addictive (M=6.63, SE=0.16) than women (M=7.63, SE=0.16, p<0.001, d=0.48).
Harm perception
The ANOVA revealed a significant main effect of warning (F1309=20.39, p<0.001, ηp 2=0.06) and sex (F1309=6.92, p=0.009, ηp 2=0.02). Text WLs on e-liquid vials increased harm perception toward e-cigarettes (Mwith WL=6.93, SE=0.19, Mwithout WL=5.68, SE=0.19, p<0.001, d=0.52) (figure 1A). In general, men perceived flavoured e-cigarettes as less harmful (M=5.94, SE=0.19) than women (M=6.67, SE=0.19, p=0.009, d=0.30).
Attention
Figure 1B shows an example of the ‘heat map’ for the click proportion in the containers’ areas that grabbed attention. This analysis was made only for the WL group. The ANOVA revealed a significant main effect of region (F1153=135.59, p<0.001, ηp 2=0.47). On average, text WLs on e-liquid vials grabbed attention 21.62% of the trials (SE=2.43), and e-liquid brand 78.38% of the trials (SE=2.43) (p<0.001, d=1.86).
Discussion
Previous studies have found that text WLs on e-cigarettes decrease young adults’ intentions to use e-cigarettes, via increasing perceived risk.17 Our results suggest that a similar effect occurs when text WLs are on e-liquid vials (ie, increase harm perception, decrease positive valence and decrease intentions to use e-cigarettes, especially in men). The results also indicated, however, that text WLs on e-liquid vials do not affect the perceived addictiveness and capture less attention than the rest of the vial (they may have limited potential to grab attention when competing with other attractive packaging elements).
Previous research showed that text WLs increased perceived harms of e-cigarettes, however, they did not always reduce the intention to use them.18 19 Our results suggested that text WLs on e-liquid vials may meet both goals successfully (ie, inform potential harms and reduce intentions to use e-cigarette). Similar to previous studies with WLs on cigarette packaging,20 this study revealed that text WLs on e-liquid vials diminished e-cigarette appeal (ie, decrease pleasant affective valence). These results suggest a lower probability of approach towards the product, presumably due to less activation of the appetitive motivational system.21 This is relevant because previous studies have found that flavoured e-cigarette ads are more appealing and elicit greater interest in buying and trying e-cigarettes.22
It is worth noting that although the content of text WLs was related to the addictive capacity of nicotine, our results showed that text WLs on e-liquid vials had no effect on the perception of addictiveness of the product. This same result has previously been found when text WLs are presented on e-cigarette advertisements.19 These results may be a consequence of the fact that e-cigarettes, especially flavoured e-cigarettes, are perceived to be a safer alternative to cigarette smoking.23 It is also possible that the attractive design (eg, candy, fruit) of e-liquid vials is not consistent with the image of an addictive product. Previous studies have found that when information about e-cigarettes is ambiguous (ie, conflicting information), the information is processed through heuristics using minimal cognitive effort.24 Given that one of the goals of WLs is to inform about the potential addictiveness of e-cigarettes, these results suggest more effective WL designs may be needed to achieve this goal. For example, colour WLs,8 pictorial WLs and different message content (eg, health hazards).25
The present study has several limitations. First, only self-report measures were evaluated; no behavioural or physiological measures were taken. Second, only one WL design was evaluated, and recent studies have found that there are differences in responses to different WL designs.8 25 Third, we did not measure the baseline of e-cigarettes perceived addictiveness, so it is possible that the lack of results on the addiction outcome may be due to high baseline knowledge/beliefs about the e-cigarettes’ addiction potential. Finally, the sample consisted only of e-cigarette non-users. Other studies should be carried out with e-cigarette users, smokers, dual users and former smokers.
Conclusion
This study provides preliminary experimental evidence of the effects of text WLs on e-liquid vials among young adult non-users of e-cigarettes. Consistent with findings from WLs on e-cigarettes,7 8 text WLs on e-liquid vials decreased young adults’ intention to use e-cigarettes and, simultaneously, increased their harm perception and decreased the appeal of the product.
However, results suggested that text WLs do not influence the perceived addictiveness of e-cigarettes and capture less attention than the rest of the attractive branding part of the product. Text WLs on e-liquid vials have limited impact on young adult non-users of e-cigarettes. New text WL designs may be needed (eg, pictorial WL) to achieve the goal to inform effectively of the potential addictiveness of flavoured e-cigarettes.
What this paper adds
What is already known on this subject
Experimental studies have shown that exposure to electronic cigarette (e-cigarette) warning labels located on product ads and product packaging led to increased harm perception and decreased usage intentions.
Flavoured e-cigarettes are especially appealing to young adults, and adolescents have reported flavours as a motivation for e-cigarette use.
What important gaps in knowledge exist on this topic
Few studies have evaluated the effect of text warning labels on flavoured e-liquid vials. Flavours are one of the main sources of motivation for e-cigarette use in adolescents and young adults.
What this paper adds
Text warning labels on e-liquid vials decrease young adults’ intention to use e-cigarettes, increase harm perception and decrease the appeal of the product (ie, decrease positive valence).
Text warning labels on e-liquid vials do not influence the perceived addictiveness of e-cigarettes and rarely grab attention.
Abstract translation
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.Ethics statements
Patient consent for publication
Ethics approval
All study procedures received ethics approval from the Universidad de los Andes Institutional Review Board.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors All authors made a substantial contribution to this research. CG contributed to the conceptualisation of the study, conducted the analyses and wrote the initial draft of the manuscript. LA-S and AV-V designed data collection tools and led data collection. All authors approved the final version.
Funding This work was supported by Universidad de los Andes under grant (853922707).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.