You are here

Article Text

Article menu
Special communication
Tobacco promotion restriction policies on social media
  1. Grace Kong1,
  2. Linnea Laestadius2,
  3. Julia Vassey3,
  4. Anuja Majmundar4,
  5. Andrea M Stroup5,
  6. Helen I Meissner6,
  7. Ziyad Ben Taleb7,
  8. Tess Boley Cruz3,
  9. Sherry L Emery8,
  10. Dan Romer9
  1. 1 Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
  2. 2 Zilber School of Public Health, University of Wisconsin—Milwaukee, Milwaukee, Wisconsin, USA
  3. 3 Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA
  4. 4 Tobacco Control Research, American Cancer Society, Inc, Atlanta, Georgia, USA
  5. 5 Westat, Rockville, Maryland, USA
  6. 6 Office of Disease Prevention, National Institutes of Health, Bethesda, Maryland, USA
  7. 7 Department of Kinesiology, College of Nursing and Health Innovation, University of Texas at Arlington, Arlington, Texas, USA
  8. 8 Social Data Collaboratory, NORC at the University of Chicago, Chicago, Illinois, USA
  9. 9 Annenberg Public Policy Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr Grace Kong, Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA; grace.kong{at}yale.edu

Abstract

Tobacco promotion is prolific on social media, with each platform setting their own restrictions on tobacco promotion and sales. We evaluated the policies related to tobacco product promotion and sales on 11 sites that are popular with youth in May 2021: Discord, Facebook, Instagram, Pinterest, Reddit, Snapchat, TikTok, Tumblr, Twitch, Twitter and YouTube. Nine of the 11 sites prohibited paid advertising for tobacco products. However, only three of them clearly prohibited sponsored content (ie, social influencers) that promotes tobacco. Six platforms restricted content that sells tobacco products and three tried to prohibit underage access to content that promotes or sells tobacco products. Although most platform policies prohibited paid tobacco advertising, few addressed more novel strategies, such as sponsored/influencer content and few had age-gating to prevent youth access. There is a pressing need to regulate tobacco promotion on social media platforms.

  • Media
  • Social marketing
  • Public policy

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/tc-2022-057348

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Current regulations are insufficient to restrict tobacco product promotion on social media.

    • Some social media platforms have begun to voluntarily restrict tobacco promotion.

    • Less known is whether social media’s self-imposed regulations are sufficient in restricting tobacco promotion.

    WHAT THIS STUDY ADDS

    • Most platforms prohibited paid ads, but few addressed novel forms of tobacco promotion and prohibited youth access.

    • Some social media platforms did not have any restrictions on tobacco promotion.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • A comprehensive restriction policy and enforcement are needed to prohibit tobacco promotion on social media.

    Introduction

    Tobacco marketing drives demand for tobacco products, among both youth and adults.1 The effects of tobacco marketing are so robust that governments around the world imposed strict limits on tobacco marketing. In the USA, the Master Settlement Agreement (MSA) in 1998 restricted the promotion of cigarettes and smokeless tobacco on billboards, magazines, television, movies and sponsored events.2 However, a variety of tobacco products (eg, cigars, hookah, e-cigarettes and pipe tobacco) and novel marketing strategies (eg, social media marketing) are not governed by the MSA.3 4

    By 2004, 168 countries had signed onto the 2003 WHO Framework Convention on Tobacco Control (FCTC), which banned ‘tobacco advertising, promotion, and sponsorship to the fullest extent possible given national constitutional principles’.5 In the USA, the 2009 Tobacco Control Act (TCA) allowed the U.S. Food and Drug Administration (FDA) to regulate manufacturing, distribution and marketing of tobacco products.6 In the face of conventional tobacco advertising, promotion and sponsorship bans, tobacco companies have used other less-regulated channels to promote their products. In particular, the rapidly changing digital media environment, such as social media, has been exploited by the tobacco industry to promote their products.7

    Tobacco marketing on social media appeals to youth

    Social media have become a significant conduit for tobacco marketing and have created a tobacco-permissive milieu that is attractive to youth.7 8 We use the term ‘social media’ to encompass a diverse selection of multimedia (text-based, image-based and video-based) platforms, which includes more traditional ‘social network’ communities like Facebook, Tumblr and Twitter and other platforms that are more often used as ‘media sharing networks’, such as Instagram, YouTube, Snapchat and TikTok. The social media ecosystem continues to develop, and more specialised social media platforms, such as Discord and Twitch, are being introduced with a focus on microcommunities such as gamers. Discord is a messaging platform that was originally directed at video gamers; however, its reach has broadened to other communities.9 Twitch is a video streaming platform that focuses on video game live streaming but also includes other content such as e-sports and music.10 These newer platforms can appeal to youth, particularly among video gamers, mainly because of their highly interactive and community-geared nature.11 Taken together, these social media platforms enable engagement with tobacco content through common features such as commenting, ‘liking’, messaging and adding other users as ‘friends’ in their own network.

    Social media is highly appealing to youth around the globe.12–14 Emerging research shows that youth are increasingly engaging with online tobacco marketing; for instance, among U.S. youth, engagement with online tobacco marketing increased from 8.7% to 20.9% (2013/2014 to 2014/2015).15 This finding is concerning because exposure to online marketing, including on social media, is associated with subsequent tobacco use initiation among youth15 and young adults16 who never used tobacco, as well as with increased frequency of use, progression to poly-tobacco use and decreased cessation among youth who use tobacco products.15 Furthermore, a scoping review showed that tobacco promotional content is common on social media accounts across different countries such as USA, New Zealand, Australia and Canada.17 This collective evidence suggests that current restriction policies on tobacco promotion may be insufficient and a closer look at the current regulatory landscape is warranted.

    Evolving tobacco product marketing strategies on social media

    Tobacco promotion on social media can be grouped into three types: paid media (eg, promotion through paid online advertisements), earned media (ie, promotion through a third party such as press mentions, consumer-generated content rather than through a company) and owned media (ie, promotion through a tobacco brand’s direct channel such as their own website or social media account).18 Promotion of tobacco products on social media platforms may use a combination of these types of marketing to permit a high level of engagement with users.

    Examples of commonly found tobacco promotion on social media can be summarised as the following: (1) Pages, posts or accounts created by the tobacco brands or tobacco retailers and features tobacco products and other news/events (owned media).19 20 (2) Social influencers, who are individuals who have a large network of followers in niche areas who promote a tobacco product by incorporating the product in their own social media content (paid/earned media).21 (3) Paid advertisements by tobacco companies that pop up in a viewer’s social media feed or run as banners (paid media).4 19 20 22 (4) Third party promotion of the tobacco on their social media (eg, bars featuring hookah in their promotional posts, planned product promotion on music videos that are shared on social media) (earned media).23 (5) Supporters of tobacco products reacting to (ie, using emojis or giving ‘likes’) on threads devoted to protobacco content or reposting links to protobacco product content such as websites/articles on their own social media pages.24 25 These promotional strategies may include direct (eg, ads featuring products/sales) and indirect methods (eg, tobacco industry advertising or promoting political agendas, corporate messaging or social issues such as #BlackLivesMatter and International Women’s Day).26 27 Using the USA as an example, some of these promotions (eg, brands/retailers promoting tobacco products on social media) may fall under the FDA’s marketing restriction policies but they continue to be present on social media.

    There is a pressing need to ensure that policies that restrict tobacco marketing both at the individual platform and at the federal level are appropriate and aligned. Social media platforms have recently come under increasing scrutiny for their lack of oversight of content that is harmful to public health.28 29 To their credit, social media platforms have begun to self-regulate paid advertisements on their platforms. For example, Facebook has policies that restrict the advertising of products that are detrimental to health including alcohol and tobacco products.30 However, the adequacy of such policies across major social media platforms as they pertain to the promotion of tobacco products has never been thoroughly examined. For instance, it is unclear whether social media platforms’ policies pertain only to paid advertisements or to other forms of promotions such as earned or owned media, which function similarly to paid advertisements. These forms of promotions are still commercial communication that aims to promote the use of tobacco products. Thus, we sought to identify social media platforms’ self-imposed policies to determine whether they have restrictions on tobacco promotion and sales.

    Methods

    We examined tobacco-related policies on social media platforms with current or emerging popularity among U.S. youth: Discord, Facebook, Instagram, Pinterest, Reddit, Snapchat, TikTok, Tumblr, Twitter, YouTube12 13 31 and Twitch.32 In May 2021, each platform was visited and terms of service and advertising policies were downloaded and reviewed for language related to tobacco products. A detailed description of social media’s policies on the restriction of tobacco promotion is reported in online supplemental table 1. These policies were reviewed by two research members to inductively identify the types of restrictions present, as well as any language about instances where tobacco products are explicitly allowed to be promoted on the platform. Once restriction types were identified, each social media platform was systematically reviewed for each restriction type by two research members.33

    Supplemental material

    Across social media platforms, we categorised the restrictions into four categories: (1) paid advertisement, (2) promotion of tobacco products, (3) sale of tobacco products and (4) underage access (table 1). Restrictions on paid advertisement included prohibiting paid advertisements for tobacco products, tobacco use venues (eg, hookah lounges) and tobacco events. Restrictions on promotion included the platform’s algorithm not ‘pushing’ or not recommending tobacco promotional content to its users and the prohibition of the creation of influencer posts with tobacco content. Restrictions on sales included prohibiting tobacco sales on the brand/vendor’s social media account or platform ‘marketplaces’. Restriction on underage access included promotional content to be shown only on age-verified accounts. Please see online supplemental table 1 for the policies of each platform that pertain to specific tobacco products when provided.

    View this table:
    Table 1

    Social media platform policies restricting the promotion and sale of tobacco products as of May 2021

    Results

    Paid tobacco ads

    Nine social media platforms explicitly prohibited paid advertising for tobacco products. However, definitions of tobacco products varied across platforms; for example, Tumblr allowed paid advertising of e-cigarettes when ‘legal in the target market’. YouTube prohibited paid tobacco ads and limited the capacity of videos promoting tobacco from being monetised by labelling them ‘limited or no ads’. Video creators can earn money by sharing the revenues of the ads placed on their videos and videos have less chance of being chosen for advertising if they are labelled as ‘limited or no ads’. Newer platforms such as Twitch and Discord did not have any tobacco promotion policies.

    Six social media platforms prohibited paid advertising for tobacco use in venues such as hookah lounges, and two social media platforms prohibited paid ads for tobacco events. Some prohibitions on tobacco product advertising also included promoting tobacco product use, which may be interpreted to include events and venues focused on tobacco use.

    Promotion

    Content that promotes tobacco products was less frequently restricted. For example, Instagram and Snapchat have policies against recommending posts that promote tobacco to other users. Policies related to sponsored tobacco content were similarly limited, with only three of the platforms, Facebook, Instagram and TikTok, having language that clearly prohibits sponsored, endorsed or partnership-based content that promotes tobacco products.

    Sales

    Six platforms prohibited or limited content that attempts to sell tobacco products, with varying policies. For example, Facebook and Instagram prohibited tobacco sales using official platform commerce tools, but explicitly allowed age-gated posts that sell tobacco products when posted by an account representing a brick-and-mortar store or ‘legitimate website or brand’; Pinterest and Reddit restricted user-to-user sales of tobacco products but did not explicitly state rules about sales from licensed retailers and YouTube prohibited posting any content that directly sells, links to, or facilitates access to tobacco products.

    Underage access

    Three platforms had specific language about age-gating on tobacco promotional content. Age-gating refers to restricting access to social media content unless an individual is signed into an age-verified account. As stated above, Facebook and Instagram restricted posts from stores that sell tobacco products to underage minors on their platforms. YouTube’s language is broader than Facebook and Instagram and indicates that content that promotes a product that contains nicotine may be age-gated or removed.

    Discussion

    As of May 2021, the majority of the self-imposed social media platform policies prohibited paid tobacco advertising but failed to address more novel strategies, such as sponsored/influencer content or promotional content on brand and retailer accounts. Interestingly, the newest social media platforms, Discord and Twitch, were the most lenient in terms of restricting their tobacco promotional content. Paid advertisements represent only part of the concern with tobacco promotion on social media. Unpaid promotional content posted by retailers and brands on their own accounts, sponsored posts made by influencers and indirect promotion of tobacco products by incorporating political messaging and social issues, are increasingly concerning.19 26 27 34

    Only three platforms explicitly restricted influencer posts with tobacco content, and two platforms did not permit user-generated tobacco promotions to be featured or recommended content on the platform. Minimising the extent to which a platform’s algorithm will push tobacco content to other users may reduce youth exposure. It is notable that most social media platforms would allow content that promotes tobacco use posted by users other than registered influencers. For example, an analysis of user-generated content on YouTube found extensive presence of misinformation about the harms of tobacco use and the portrayal of tobacco use as an exciting activity (eg, blowing smoke rings) without any indication of the ill effects of the behaviour.35 Such portrayals frequently involved youth using e-cigarettes.36

    The prohibition of tobacco product sales varied, with some prohibiting sales on their official commerce platforms and others prohibiting user-to-user transactions, which could include gifts involving tobacco. Although these general sales prohibitions may restrict youth from purchasing, policies were not consistent across platforms and there were some cases where selling was allowed. For instance, Facebook and Instagram did not allow selling tobacco products in their “marketplace” but allowed brands and retail stores to sell tobacco products on their age-gated posts. Facebook, Instagram and YouTube were the only platforms that explicitly had an age-gating policy that reflected FDA’s policy to prohibit the sale of tobacco products to minors, and no platforms mentioned mandated warning statements.

    Violation of self-imposed tobacco marketing restrictions is common

    It should be stressed that having a policy in place is not a guarantee that the policy will be enforced. Violation of platform policies is common as can be seen in examples shown in figures 1 and 2. Figure 1 shows an example of a violation of social media platform policy that prohibits influencer posts with tobacco content. It shows a known influencer giving away an e-cigarette product through soliciting social media engagement (ie, liking, commenting). Figure 2 shows a violation of another social media platform policy that requires content that promotes a product that contains nicotine to be age-gated or removed and prohibits the selling of the product. The content shown in this figure was accessed through a non-age verified account and this post had an external link where the nicotine product can be purchased.

    Figure 1
    Figure 1

    An example of violation of social media’s platform policy that prohibits influencer posts with tobacco content. The influencer status of the “model” featured on this social media post was confirmed by a secondary source.

    Figure 2
    Figure 2

    An example of violation of social media’s platform policy that requires content that promotes a product that contains nicotine to be age-gated or removed and prohibits selling of the product (ie, an external link for purchasing).

    Age-gating is one way to restrict youth access; however, prior research suggests that age-gating policies are not effectively enforced for tobacco-related pages on social media platforms and sponsored posts do not always disclose financial relationships or make use of official branded post tools that would identify them on a given platform.4 20 22 It is also unclear if platforms enforce policies consistently under different jurisdictions internationally. Additionally, age-gating is only a minor step towards preventing youth access since circumventing age restrictions is easy; underage youth can simply lie about their age to create and access age-restricted content on social media.37 38 Although platforms are now exploring novel ways of ensuring more accurate age verification, it is not yet clear how effective these strategies will be.39

    Need for comprehensive tobacco marketing restrictions on social media

    Prioritising tobacco marketing restrictions and enforcement of these restrictions on social media is crucial because unlike the traditional one-way media (eg, television, radio, newspaper), social media offers the tobacco industry a powerful interactive tool to appeal to younger generations of customers, including never users, and to renormalise tobacco use by associating it with youth culture.7 Indeed, the heavy presence of tobacco marketing on various social media platforms has been well-documented.4 These tobacco promotional activities represent a significant public health concern because of the popularity of social media use among youth.12 29 Further, exposure to tobacco marketing on social media is associated with subsequent use of tobacco products among youth15 40 and young adults.16

    Despite the variety of tobacco promotion that is occurring on social media, FDA’s current restrictions on tobacco marketing (ie, requiring health warnings, prohibiting the sale and distribution of products with unsubstantiated modified risk tobacco product health claims or false or misleading claims on labelling or advertising and prohibiting the distribution of free samples) do not apply to all forms of tobacco promotion. Nevertheless, the FDA’s recent directives seem to extend to influencer marketing. In 2019, the FDA and the U.S. Federal Trade Commission jointly issued warning letters to four companies who were using social media influencers to market e-liquids for failure to include nicotine warning labels in their efforts to prevent youth tobacco use, particularly e-cigarette use.41 42 In 2018, the WHO established a working group to ‘develop specific guidelines to address […] the depiction of tobacco in the entertainment media […] taking account of technological advances […] such as the Internet and mobile communications’.43 This group concluded that the original provisions of the 2003 FCTC adequately cover social media promotion of tobacco products and acknowledged the need to address cross-border tobacco promotions on digital media.

    Potential solutions to restrict tobacco promotion on social media

    It is important that regulations are up to date and flexible to keep pace with the current tobacco marketing that is occurring on social media. Currently, the TCA gives the FDA general authority to regulate tobacco marketing, including on social media; however, it does not explicitly mention social media, which indicates that further actions can be taken. To this end, the FDA can specifically restrict tobacco advertising in youth-appealing media and events, which include social media. The FDA can also require tobacco companies to maintain a continuously updated public database of all their social media content posted from their official social media accounts (eg, shared paid reviews, cross-promotions). Such requests may also include content originating from affiliates such as sponsored partners’ social media accounts (eg, targeted audience characteristics per sponsored post, dollar amount spent for a sponsored review) and their associated meta-data (eg, list of followers). Public disclosure of social media marketing may allow community members, including researchers, to monitor tobacco promotion on social media to inform federal and social media platform policies. This effort may facilitate timely monitoring of tobacco companies’ social media marketing practices.

    Future regulations must consider cross-border advertising of tobacco products. Social media makes it easy for promotional content to be created, shared and viewed in other countries with different jurisdictions and provides an optimal platform for the tobacco industry to circumvent tobacco promotional restriction policies. For example, U.S.-based influencers who promote tobacco content do not exist in isolation; they actively communicate with a network of international influencers via commenting and liking each other’s posts and cross-promoting each other’s content.44 This can create an international net of tobacco promoters who expose their followers to tobacco promotional content outside of their country’s border. Cross-border tobacco promotion has been less studied by tobacco control researchers because non-native language and locations from other countries often get omitted from surveillance of social media (typically non-English and non-U.S.), which further creates a permissible milieu for cross-border advertising to proliferate. An international effort is needed to prevent the tobacco industry from exploiting this loophole.

    Social media platforms have incorporated a wide range of strategies to protect vulnerable populations from harmful content. For example, Twitter prompts users to read an article before retweeting it to their network;45 Facebook requires ads pertaining to social issues, elections or politics to be accompanied by disclaimers46 and Instagram has begun applying informational labels to posts about COVID-19.47 At the very least, social media platforms can apply informational/warning labels on all tobacco content on their platforms. In addition, platforms should clearly define policies that prohibit promoting and selling tobacco products using both direct and indirect methods (eg, influencers marketing the product) and explicitly state policies that prohibit youth from accessing tobacco promotional content. Importantly, how these policies will be enforced must be explained. Finally, social media platforms can remove content that is misleading and potentially harmful to public health, as it has done regarding the COVID-19 pandemic. As policies change over time, it will be important for researchers and regulators to revisit the landscape of social media platform tobacco policies.

    The recent U.S. Surgeon General Advisory highlighted steps that social media platforms can take to protect public health from misinformation during the COVID-19 pandemic.28 Like the COVID-19 pandemic, tobacco use is a recognised threat to public health that would justify similar treatment on social media. For instance, similar guidelines can be also applied to restrict tobacco promotion on these platforms including, (1) assess the harms of tobacco promotion on their platforms and take responsibility for the harms that this promotion can cause; (2) offer open access to real-time data to researchers to determine the spread and effects of tobacco promotion; (3) strengthen monitoring of tobacco promotion; (4) prioritise early detection of tobacco promotion; (5) determine what internal policies and algorithms may contribute to tobacco promotion and (6) amplify information from accurate sources about the harms of tobacco products.

    In addition to platform-specific policies and efforts, it will be critical to strengthen the regulatory framework around issues pertaining to algorithm-driven exposure to content related to tobacco to limit exposure across all platforms. Research suggests that the platform algorithms are designed to expose audiences to homogenous content over time.48 It is possible that those who encounter tobacco-related information initially may be exposed to such content even more in the future.22 The proposed Algorithmic Justice and Online Platform Transparency Act of 202149 in the USA would require social media platforms to disclose how they use algorithms and what information they use to run them. By making all social media platforms accountable, this proposed legislation would help protect vulnerable populations, such as youth from being targeted with harmful content, such as tobacco promotional content.

    Summary

    As of May 2021, existing social media platform policies related to restricting promotion and sales of tobacco products are insufficient to restrict the overall proliferation of this content on social media. We examined tobacco promotion policies on social media platforms from the USA; however, it is important to acknowledge that social media reach is broad. Across the globe, 3.6 billion people are using social media and use rate is projected to grow.50 It is time to keep the tobacco industry accountable so that they stop promoting their products to youth on digital platforms such as social media, and for social media platform leadership and the regulatory authorities to set and enforce strong policies that restrict tobacco promotional content on social media.

    Ethics statements

    Patient consent for publication

    References

    1. ↵
      1. Centers for Disease Control and Prevention
      . Surgeon General’s Report: The Health Consequences of Smoking—50 Years of Progress. Cent Dis Control Prev 2014, 2014. Available: https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm [Accessed 08 Oct 2021].
    2. ↵
      1. National Association of Attorneys General
      . The master settlement agreement, 2021. Available: https://www.naag.org/our-work/naag-center-for-tobacco-and-public-health/the-master-settlement-agreement/ [Accessed 05 Oct 2021].
    3. ↵
      2. Liang Y ,
      3. Zheng X ,
      4. Zeng DD , et al
      . Exploring how the tobacco industry presents and promotes itself in social media. J Med Internet Res 2015;17:e3665.doi:10.2196/jmir.3665 pmid:http://www.ncbi.nlm.nih.gov/pubmed/25608524
      OpenUrlPubMed
    4. ↵
      2. O'Brien EK ,
      3. Hoffman L ,
      4. Navarro MA , et al
      . Social media use by leading US e-cigarette, cigarette, smokeless tobacco, cigar and hookah brands. Tob Control 2020;29:e87–97.doi:10.1136/tobaccocontrol-2019-055406 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32217772
      OpenUrlAbstract/FREE Full Text
    5. ↵
      1. World Health Organization (WHO)
      . WHO framework convention on tobacco control. Switzerland: World Health Organization, 2003.
    6. ↵
      1. U.S. Food and Drug Administration
      . Family Smoking Prevention and Tobacco Control Act - An Overview, 2020. Available: https://www.fda.gov/tobacco-products/rules-regulations-and-guidance/family-smoking-prevention-and-tobacco-control-act-overview [Accessed 17 May 2021].
    7. ↵
      2. Freeman B
      . New media and tobacco control. Tob Control 2012;21:139–44.doi:10.1136/tobaccocontrol-2011-050193 pmid:http://www.ncbi.nlm.nih.gov/pubmed/22345236
      OpenUrlAbstract/FREE Full Text
    8. ↵
      1. U.S. Department of Health and Human Services
      . Preventing tobacco use among youth and young adults: a report of the surgeon General. Smok Tob use, 2012. Available: http://www.cdc.gov/tobacco/data_statistics/sgr/2012/ [Accessed 24 Aug 2017].
    9. ↵
      1. Discord
      . About Discord - Our Mission and Values. Discord, 2021. Available: https://discord.com/company [Accessed 18 Oct 2021].
    10. ↵
      1. Twitch
      . About twitch, 2021. Available: https://www.twitch.tv/p/en/about/ [Accessed 18 Oct 2021].
    11. ↵
      2. Bankov B
      . The impact of social media on video game communities and the gaming industry. Conf. DEP. inform. Bulgaria: Publishing house Science and Economics Varna, 2019: 198–208.
    12. ↵
      2. Anderson M ,
      3. Jiang J
      . Teens, Social Media & Technology 2018, 2018. https://www.pewresearch.org/internet/2018/05/31/teens-social-media-technology-2018/
    13. ↵
      1. Statista Research Department
      . Most popular social networks of teenagers in the United States from fall 2012 to fall 2021, 2021. Available: https://www.statista.com/statistics/250172/social-network-usage-of-us-teens-and-young-adults/ [Accessed 05 Oct 2021].
    14. ↵
      1. Statista Research Department
      . Most popular social networks worldwide as of October 2021, Ranked by number of active users. Statista, 2021. Available: https://www.statista.com/statistics/272014/global-social-networks-ranked-by-number-of-users/ [Accessed 15 Feb 2022].
    15. ↵
      2. Soneji S ,
      3. Yang J ,
      4. Knutzen KE , et al
      . Online tobacco marketing and subsequent tobacco use. Pediatrics 2018;141:e20172927.doi:10.1542/peds.2017-2927 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29295893
      OpenUrlCrossRefPubMed
    16. ↵
      2. Clendennen SL ,
      3. Loukas A ,
      4. Vandewater EA , et al
      . Exposure and engagement with tobacco-related social media and associations with subsequent tobacco use among young adults: a longitudinal analysis. Drug Alcohol Depend 2020;213:108072.doi:10.1016/j.drugalcdep.2020.108072 pmid:http://www.ncbi.nlm.nih.gov/pubmed/32563115
      OpenUrlPubMed
    17. ↵
      2. McCausland K ,
      3. Maycock B ,
      4. Leaver T , et al
      . The messages presented in electronic cigarette-related social media promotions and discussion: Scoping review. J Med Internet Res 2019;21:e11953.doi:10.2196/11953 pmid:http://www.ncbi.nlm.nih.gov/pubmed/30720440
      OpenUrlCrossRefPubMed
    18. ↵
      2. Stephen AT ,
      3. Galak J
      . The effects of traditional and social earned media on sales: a study of a microlending marketplace. Journal of Marketing Research 2012;49:624–39.doi:10.1509/jmr.09.0401
      OpenUrlCrossRef
    19. ↵
      2. Jackler RK ,
      3. Li VY ,
      4. Cardiff RAL , et al
      . Promotion of tobacco products on Facebook: policy versus practice. Tob Control 2019;28:67–73.doi:10.1136/tobaccocontrol-2017-054175 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29622602
      OpenUrlAbstract/FREE Full Text
    20. ↵
      2. Kong G ,
      3. Kuguru KE ,
      4. Bhatti H , et al
      . Marketing content on e-cigarette brand-sponsored Facebook profile Pages. Subst Use Misuse 2021;56:442–8.doi:10.1080/10826084.2021.1878223 pmid:http://www.ncbi.nlm.nih.gov/pubmed/33596764
      OpenUrlPubMed
    21. ↵
      2. De Veirman M ,
      3. Cauberghe V ,
      4. Hudders L
      . Marketing through Instagram influencers: the impact of number of followers and product divergence on brand attitude. Int J Advert 2017;36:798–828.doi:10.1080/02650487.2017.1348035
      OpenUrl
    22. ↵
      2. Laestadius L ,
      3. Wang Y
      . Youth access to JUUL online: eBay sales of JUUL prior to and following FDA action. Tob Control 2019;28:617–22. doi:10.1136/tobaccocontrol-2018-054499 pmid:30185531
      OpenUrlAbstract/FREE Full Text
    23. ↵
      2. Allem J-P ,
      3. Escobedo P ,
      4. Cruz TB , et al
      . Vape pen product placement in popular music videos. Addict Behav 2019;93:263–4.doi:10.1016/j.addbeh.2017.10.027 pmid:http://www.ncbi.nlm.nih.gov/pubmed/29128149
      OpenUrlPubMed
    24. ↵
      2. Allem J-P ,
      3. Chu K-H ,
      4. Cruz TB , et al
      . Waterpipe promotion and use on Instagram: #hookah. Nicotine Tob Res 2017;19:1248–52.doi:10.1093/ntr/ntw329 pmid:http://www.ncbi.nlm.nih.gov/pubmed/28077449
      OpenUrlPubMed
    25. ↵
      2. Allem J-P ,
      3. Escobedo P ,
      4. Chu K-H , et al
      . Images of little cigars and cigarillos on Instagram identified by the hashtag #swisher: Thematic analysis. J Med Internet Res 2017;19:e255.doi:10.2196/jmir.7634 pmid:http://www.ncbi.nlm.nih.gov/pubmed/28710057
      OpenUrlPubMed
    26. ↵
      2. Hunt D ,
      3. Hefler M ,
      4. Freeman B
      . Tobacco industry exploiting international women's day on social media. Tob Control 2020;29:e157–8.doi:10.1136/tobaccocontrol-2019-055183 pmid:http://www.ncbi.nlm.nih.gov/pubmed/31462581
      OpenUrlFREE Full Text
    27. ↵
      2. Heley K ,
      3. Popova L ,
      4. Moran M , et al
      . Targeted tobacco marketing in 2020: the case of #BlackLivesMatter. Tob Control 2023;32:530–3. doi:10.1136/tobaccocontrol-2021-056838
      OpenUrlFREE Full Text
    28. ↵
      1. Office of the Surgeon General
      . Confronting Health Misinformation: The U.S. Surgeon General’s Advisory on Building a Healthy Information Environment. Washington, DC: US Department of Health and Human Services, 2021.
    29. ↵
      2. Volkmer I
      . Social media and COVID-19: a global study of digital crisis interaction among Gen Z and millennials. Study Conducted by Wunderman Thompson, University of Melbourne, Pollfish and the World Health Organization: University of Melbourne, 2021.
    30. ↵
      2. Azad A
      . Facebook and Instagram to restrict content related to alcohol, tobacco products, 2019. https://www.cnn.com/2019/07/24/health/facebook-instagram-alcohol-tobacco-bn
    31. ↵
      2. Ballard J
      . Teens use these social media platforms the most, 2019. Available: https://today.yougov.com/topics/lifestyle/articles-reports/2019/10/25/teens-social-media-use-online-survey-poll-youth [Accessed 05 Oct 2021].
    32. ↵
      2. Shearer E ,
      3. Mitchell A
      . News use across social media platforms in 2020, 2021. https://www.pewresearch.org/journalism/2021/01/12/news-use-across-social-media-platforms-in-2020/
    33. ↵
      2. Gale NK ,
      3. Heath G ,
      4. Cameron E , et al
      . Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 2013;13:117.doi:10.1186/1471-2288-13-117 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24047204
      OpenUrlCrossRefPubMed
    34. ↵
      2. Navarro MA ,
      3. O’Brien EK ,
      4. Ganz O , et al
      . Influencer prevalence and role on cigar brand Instagram Pages. Tob Control 2021;30:e33–6. doi:10.1136/tobaccocontrol-2020-055994 pmid:33046583
      OpenUrlAbstract/FREE Full Text
    35. ↵
      2. Romer D ,
      3. Reese Z ,
      4. Jamieson PE
      . Misleading tobacco content is on the rise on YouTube. Harv Kennedy Sch Misinformation Rev 2020.doi:10.37016/mr-2020-010
    36. ↵
      2. Vassey J ,
      3. Allem J-P ,
      4. Barker J , et al
      . E-cigarette use and promotion by social media influencers during videogame play on twitch. Tob Control 2023;32:526–7. doi:10.1136/tobaccocontrol-2021-056828 pmid:34625511
      OpenUrlFREE Full Text
    37. ↵
      2. Pasquale L ,
      3. Zippo P ,
      4. Curley C , et al
      . Digital age of consent and age verification: can they protect children? IEEE Softw 2022;39:50–7.doi:10.1109/MS.2020.3044872
      OpenUrlCrossRef
    38. ↵
      1. LERO
      . Children can bypass age verification procedures in popular social media apps by lying, 2021. Available: https://lero.ie/news-and-events/children-can-bypass-age-verification-procedures-popular-social-media-apps-lying [Accessed 06 Jul 2022].
    39. ↵
      1. Instagram
      . New ways to verify your age on Instagram, 2022. Available: https://about.instagram.com/blog/announcements/new-ways-to-verify-age-on-instagram [Accessed 06 Jul 2022].
    40. ↵
      2. Soneji S ,
      3. Pierce JP ,
      4. Choi K , et al
      . Engagement with online tobacco marketing and associations with tobacco product use among U.S. youth. J Adolesc Health 2017;61:61–9.doi:10.1016/j.jadohealth.2017.01.023 pmid:http://www.ncbi.nlm.nih.gov/pubmed/28363720
      OpenUrlPubMed
    41. ↵
      1. U.S. Food and Drug Administration
      . FDA, FTC take action to protect kids by citing four firms that make, sell flavored e-liquids for violations related to online posts by social media influencers on their behalf. FDA news release, 2019. Available: https://www.fda.gov/news-events/press-announcements/fda-ftc-take-action-protect-kids-citing-four-firms-make-sell-flavored-e-liquids-violations-related [Accessed 05 Oct 2021].
    42. ↵
      1. U.S. Food and Drug Administration
      . FDA’s Youth Tobacco Prevention Plan, 2020. Available: https://www.fda.gov/tobacco-products/youth-and-tobacco/fdas-youth-tobacco-prevention-plan [Accessed 05 Oct 2021].
    43. ↵
      1. World Health Organization (WHO)
      . Conference of the parties to the WHO framework convention on tobacco control. Geneva, Switzerland, 2018.
    44. ↵
      2. Vassey J ,
      3. Valente T ,
      4. Barker J , et al
      . E-cigarette brands and social media influencers on Instagram: a social network analysis. Tob Control 2023;32:e184–91. doi:10.1136/tobaccocontrol-2021-057053 pmid:35131947
      OpenUrlAbstract/FREE Full Text
    45. ↵
      1. Twitter
      . How to Retweet. Retweet, 2021. Available: https://help.twitter.com/en/using-twitter/how-to-retweet [Accessed 05 Oct 2021].
    46. ↵
      1. Facebook for Business Help Center
      . How disclaimers work for ads about social issues, elections or politics. disclaimers work ads soc issues elections Polit, 2021. Available: https://www.facebook.com/business/help/198009284345835 [Accessed 05 Oct 2021].
    47. ↵
      1. Instagram
      . Helping people stay safe and informed about COVID-19 vaccines, 2021. Available: https://about.instagram.com/blog/announcements/continuing-to-keep-people-safe-and-informed-about-covid-19 [Accessed 05 Oct 2021].
    48. ↵
      2. Tufekci Z
      . Youtube, the great Radicalizer, 2018. The new York times. Available: https://www.nytimes.com/2018/03/10/opinion/sunday/youtube-politics-radical.html [Accessed 05 Oct 2021].
    49. ↵
      2. Feiner L
      . New bill would “open up Big Tech’s hood,” make companies explain how they decide which content to show. CNBC, 2021. Available: https://www.cnbc.com/2021/05/28/markey-matsui-bill-would-force-social-media-content-algorithm-transparency.html [Accessed 05 Oct 2021].
    50. ↵
      1. Statista Research Department
      . Number of social network users worldwide from 2017 to 2025, 2020. Available: https://www.statista.com/statistics/278414/number-of-worldwide-social-network-users/ [Accessed 15 Feb 2022].

    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

    • X @gracekongphd, @LinneaLaestad, @JVassey, @AnujaMajmundar, @sherryemery

    • Contributors Study conception and design: GK, LL, JV, AM, AMS, HIM, ZBT, TBC, SLE, DR. Data collection: LL, JV, ZBT. Analysis and interpretation of results: GK, LL, JV, AM, AMS, HIM, ZBT, TBC, SLE, DR. Draft manuscript preparation/edits: GK, LL, JV, AM, AMS, HIM, ZBT, TBC, SLE, DR. All authors reviewed the results and approved the final version of the manuscript.

    • Funding This study is a cross-institution collaborative project from the Marketing Influences Special Interest Group (SIG) supported, in part, by the Center for Coordination of Analytics, Science, Enhancement and Logistics (CASEL) in Tobacco Regulatory Science U54DA046060-01 (National Institute of Drug Abuse (NIDA) and the Food and Drug Administration’s Center for Tobacco Products (FDA CTP). Support for authors was also provided by NIDA and FDA CTP awards U54DA036151 (Kong), R01DA049878 (Kong), R01DA051000 (Emery), and U54DA046060-01 (Stroup) as well as NCI and FDA CTP award P50CA180905 (Cruz and Vassey).

    • 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.