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Optimising messages and images for e-cigarette warnings
  1. Allison J Lazard1,2,
  2. Mohammad Ebrahimi Kalan2,3,
  3. Sydney Nicolla1,
  4. Marissa G Hall2,4,
  5. Kurt M Ribisl2,4,
  6. Jennifer Mendel Sheldon2,4,
  7. Callie Whitesell4,
  8. Tara L Queen4,
  9. Noel T Brewer2,4
  1. 1Hussman School of Journalism and Media, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  2. 2Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  3. 3School of Health Professions, Eastern Virginia Medical School, Norfolk, Virginia, USA
  4. 4Department of Health Behavior, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  1. Correspondence to Dr Allison J Lazard, Hussman School of Journalism and Media, The University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; lazard{at}


Background The US Food and Drug Administration (FDA) requires electronic cigarettes (e-cigarettes) to have a single addiction warning, but many other health harms are associated with vaping and warnings grow stale over time. We aimed to develop new warning messages and images to discourage e-cigarette use.

Methods Participants were 1629 US adults who vaped or smoked. We randomised each participant to evaluate 7 of 28 messages on newly developed warning themes (metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, addiction), and the current FDA-required warning (total of 8 messages). Then, participants evaluated images of hazards (eg, metal), internal harms (eg, organ damage) or people experiencing harms.

Results Regarding intended effects, new warning themes all discouraged vaping more than the current FDA-required warning (all p<0.001), led to greater negative affect (all p<0.001) and led to more anticipated social interactions (all p<0.001). The most discouraging warnings were about toxic metals exposure. Regarding unintended effects, the new themes led to more stigma against people who vape (6 of 7 themes, p<0.001) and led to a greater likelihood of thinking vaping is more harmful than smoking (all 7 themes, p<0.001), although unintended effects were smaller than intended effects. Images of harms (internal or people experiencing) discouraged vaping more than images of hazards (all p<0.001).

Discussion Vaping warning policies should communicate a broader range of hazards and harms, beyond addiction, to potentially increase awareness of health harms. Images of internal harm or people experiencing harms may be particularly effective at discouraging vaping.

  • packaging and labelling
  • electronic nicotine delivery devices
  • addiction

Data availability statement

Data are available on reasonable request.

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  • Contributors Conceptualisation: AJL, SN, MGH, KMR, JMS, CW, NTB. Methodology: AJL, SN, MGH, KM, JMS, CW, NB. Formal analysis: AJL, MEK, TLQ. Investigation: JMS, NTB. Writing—original draft: AJL, MEK, SN, NTB. Writing—review and editing: AJL, MEK, SN, MGH, KMR, JMS, CW, TLQ, NTB. Visualisation: AJL, SN, JMS. Supervision: NTB. Project administration: JMS. Guarantor: AJL.

  • Funding Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R01DA048390. K01HL147713 from the National Heart, Lung, and Blood Institute of the National Institutes of Health supported Marissa Hall’s time working on the paper.

  • Competing interests KMR is a paid expert scientist in litigation against e-cigarette and tobacco companies.

  • 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.