The rapid increase in the use of electronic or e-cigarettes among adolescents and younger adults continues to garner national attention and concern in the United States. Given that nearly all e-cigarettes contain nicotine,¹ public health officials worry that rates of addiction to tobacco and other drugs will increase in young people, as early nicotine exposure can harm the brain and increase addiction susceptibility.^2-4 A substantial body of evidence shows an association between e-cigarette use and future combustible tobacco use, with some research suggesting that young adult e-cigarette users are 4 times more likely to smoke cigarettes within 18 months compared with their nicotine-naive peers.^5,6 In addition, recent vaping-related illnesses reported by more than 2000 individuals have led to 39 deaths.⁷ e-Cigarette use has been associated with not only lung problems but also adverse cardiovascular effects.^8,9

Over the past decade, public education mass media campaigns have been shown to be successful in changing tobacco-related attitudes, intentions, and behaviors among youth and young adults. In 2014, the national truth® campaign re-launched a new phase of the campaign targeted at a broad audience of youth and young adults, aged 15–21, to help end the tobacco epidemic. The study sample for this analysis is drawn from the Truth Longitudinal Cohort (TLC), a probability-based, nationally representative cohort designed to evaluate the relationship between awareness of truth media messages and changes in targeted attitudes, beliefs, and behaviors over time. The sample for this study was limited to those with data at baseline and three subsequent follow-up surveys (n = 7536). Logistic regression models indicate that truth ad awareness is significantly associated with increases in targeted anti-tobacco attitudes as well as reduced intentions to smoke over time, holding constant baseline attitudes and intentions. Results also suggest a dose-response relationship in that higher levels of truth ad awareness were significantly associated with higher likelihood of reporting agreement across all five attitudinal constructs: anti-smoking imagery, anti-social smoking sentiment, anti-tobacco social movement, anti-tobacco industry sentiment, and independence. Longitudinal results indicate a significant dose-response relationship between awareness of the new phase of the truth campaign and campaign-targeted attitudes and intentions not to smoke among youth and young adults. Findings from this study confirm that a carefully designed anti-tobacco public education campaign aimed at youth and young adults is a key population-level intervention within the context of an expanding tobacco product landscape and a cluttered media environment. As tobacco use patterns shift and new products emerge, evidence-based public education campaigns can play a central role in helping the next generation to reject tobacco. Public education mass media campaigns are a key component to changing tobacco use attitudes and behavior, particularly among youth and young adults.

Objectives: To assess the quality of evidence on the effectiveness of local US laws restricting the sale of flavored tobacco products. Methods: We conducted a systematic search and qualitative scoping review of English-language papers published through May 2020 that evaluated flavored tobacco sales policies implemented by US jurisdictions during 2010–2019. We constructed a conceptual model for flavored and menthol tobacco sales restriction outcomes, assigned GRADE quality of evidence ratings to policy outcomes evaluated through the included studies, and summarized factors that might explain weak or inconsistent findings. Results: We found moderate to high quality of evidence associating policy implementation with reduced availability, marketing, and sales of policy-restricted products, and decreased youth and adult tobacco use of these products; however, policy exclusions and exemptions, implementation challenges, tobacco industry actions (e.g., marketing of concept-named flavored products; exploiting policy exemptions for certain store types), and consumer responses (e.g., cross-border or illicit purchasing) might undermine or mitigate intended policy effects. Conclusions: Flavored and menthol tobacco product sales restrictions implemented and evaluated in US jurisdictions appear to have achieved some of their intended outcomes; however, deficiencies in study designs, methods, and metrics could contribute to equivocal findings on quality of evidence associating policy implementation and outcomes. Gaps in the evidence are beginning to be filled with research using more rigorous study designs, improved measurement and analytic methods, and longer-term follow-up. Implications: In the absence of comprehensive federal action, US jurisdictions have the obligation to restrict flavored and menthol product sales to protect vulnerable populations from tobacco-related harms. The considerable expenditure of financial resources, political will, and time dedicated to policy adoption and implementation argue for evaluation studies designed to maximize the quality of evidence. This review offers generalizable insights into evaluation findings that can inform efforts to enhance tobacco control policy implementation and impact in the US and globally.

Introduction Nicotine pouches are gaining popularity, yet their marketing is understudied. Methods Using Numerator advertising data from January 2019 to September 2021 regarding three popular brands of nicotine pouch in the USA—Zyn (by Swedish Match, introduced in the USA in July 2016), On! (Altria, August 2016) and Velo (RJ Reynolds, July 2019)—we examined (1) general advertising characteristics (eg, media type, year); (2) ad content (ie, headlines and imagery themes); (3) prominent media channels (ie, specific websites, magazines, etc); and (4) ad expenditures. Results There were 286 unique ads (Zyn: 44.4%; On!: 2.8%; Velo: 52.8%), 119 143 occurrences (Zyn: 3.5%; On!: 0.5%; Velo: 96.0%) and $24 774 650 total expenditures (Zyn: 4.7%; On!: 0.6%; Velo: 94.7%). The greatest proportion of ad occurrences and expenditures were accounted for by radio (75.9% and 28.2%, respectively) and television (16.2% and 56.5%), followed by mobile (0.5% and 7.2%) and online display (6.7% and 3.6%). Across ad occurrences and expenditures, prominent headline themes included ‘freedom’ (26.0% and 17.1%, respectively), ‘brand’ (9.6% and 18.6%) and ‘flavour’ (16.4% and 7.6%); images mainly featured the product alone (61.4% and 56.1%), text (16.2% and 24.6%) or men (8.7% and 8.6%); and prominent channel themes were entertainment (34.7% and 37.3%), news/weather (14.3% and 21.7%), business/finance (12.9% and 9.0%) and sports (9.5% and 1.0%). Zyn and On! prioritised online display and print; Velo prioritised radio and television. Zyn’s and Velo’s headlines focused on ‘freedom’, with Zyn also emphasising ‘brand’ and Velo ‘innovation’; On!’s headlines emphasised ‘flavour’. Conclusions Regulatory efforts must be informed by surveillance of nicotine pouch marketing and impacts on consumer subgroups (eg, young people).

Objective To explore patterns in flavoured e-cigarette sales following Juul Labs’ 2019 removal of mint-flavoured products and the Food and Drug Administration’s (FDA) 2020 e-cigarette flavour guidance which prohibits flavoured cartridge-based sales, but allows for the sale of tobacco-flavoured and menthol-flavoured cartridges, open-system and disposable e-cigarettes. Methods We examined Nielsen Retail Scanner data from September 2013 to March 2020. Inflation-adjusted sales dollars for e-liquid-containing products were classified into five flavour categories (fruit, menthol, mint, tobacco and other). Results Following the Juul Labs 2019 and FDA 2020 actions, total e-cigarette sales declined; however, menthol-flavoured e-cigarette sales dollars increased, while mint-flavoured e-cigarette sales dollars decreased in both instances. Juul Labs’ removal of mint-flavoured products was followed by a 59.4% increase in the market share of menthol-flavoured e-cigarettes over 4 weeks. The FDA’s 2020 guidance was followed by a 54.5% increase in the market share of menthol-flavoured e-cigarettes over 4 weeks and a 82.8% increase over 8 weeks. Conclusions Juul Labs’ self-regulation and the current FDA flavour guidance were followed by a shift towards menthol-flavoured e-cigarettes. Industry self-regulation and current federal guidance appear insufficient in reversing the youth vaping epidemic. E-cigarettes must be fully regulated as a tobacco product including the removal of flavoured e-cigarettes, including menthol, from the market to reduce youth e-cigarette use.