Importance of online exposures to pro-tobacco messaging

The Article by Chuanwei Ma and colleagues, published in The Lancet Global Health, on the trends in exposure to pro-tobacco and anti-tobacco advertisements in young adolescents aged 12–16 years found that, globally, a high proportion of young people recalled past 30-day exposure to pro-tobacco messaging.¹ Encouragingly, the authors also reported that exposure to pro-tobacco messaging among young people has dropped in 111 (92·5%) of countries from 1999 to 2018. The authors noted that the data source used in this article, the Global Youth Tobacco Survey, only queries pro-tobacco messaging exposures from television, videos, or movies and at points of sale (such as stores, shops, kiosks, supermarkets, markets, restaurants, shops, and convenient stores). As these items do not assess exposure to pro-tobacco messaging online, it is possible that the reported declines in pro-tobacco messaging exposures instead reflect the fact that tobacco companies have pivoted to advertising through online media.²

In several countries, a substantial proportion of young people report recent exposure to pro-tobacco messaging online, both from the tobacco industry and from their peers.^3,4 Exposure to pro-tobacco messages online, including on social media, has consistently been associated with increased risk of tobacco use among young people.^3,4 As with exposure via other media, online exposure to pro-tobacco messaging normalises tobacco use and contributes to positive attitudes towards tobacco products.^5,6 However, online pro-tobacco messaging exposures can be especially impactful, because young people who encounter pro-tobacco messaging online can interact with the messages by liking or commenting on a social media post, clicking an advertisement to visit an online tobacco retailer, or signing up to receive tobacco coupons.² With today’s youth spending an increasing amount of their time online, conducting surveillance of online pro-tobacco messaging exposures among young people is crucially important.

Beyond the negative effects of online pro-tobacco messaging exposures on youth overall, tobacco companies deftly use online advertising to target specific audience segments, including lesbian, gay, bisexual, and transgender (LGBT) populations and youth with lower socioeconomic status.^4,7 With the established links between pro-tobacco messaging exposure and tobacco use outcomes, the outcome of this targeted marketing is the exacerbation of tobacco use disparities, and consequently tobacco-associated health disparities, such as cancer. Indeed, LGBT individuals and people with lower socioeconomic status have an increased risk of tobacco-related cancers than their non-LGBT and higher socioeconomic status counterparts.^8,9 Thus, understanding global trends in young peoples’ exposure to pro-tobacco messaging online is important not only for youth overall, but also to address existing health disparities.

As governments and social media companies enact policies to limit the ability of tobacco companies to target youth and other vulnerable populations with pro-tobacco messaging online, the tobacco industry exploits loopholes in these policies.¹⁰ Although paid advertisements for tobacco products are prohibited on most social media sites, social media influencers promoting tobacco products are often permitted.¹⁰ These influencers, part of a broad international network with ties to hundreds of tobacco brands, skirt governments’ and social media sites’ policies against targeting youth with pro-tobacco messaging.¹⁰ Most social media websites also permit the recommendation of posts of user-generated pro-tobacco content by the platform (ie, to raise the visibility of a pro-tobacco post generated by a peer).¹⁰ Until these loopholes are closed, youth exposures to pro-tobacco messaging on social media will continue.

In summary, although Ma and colleagues’ findings that youth exposure to pro-tobacco messaging via traditional media sources were encouraging, we hope that future research will be equipped to investigate exposure to pro-tobacco messaging online at a global scale. Updating the pro-tobacco messaging exposure measure on the Global Youth Tobacco Survey to include online exposure, or adding a new item to specifically assess online exposure, would allow for this improved surveillance. Additionally, closing loopholes in existing policies to prevent social media influencers from advocating on behalf of tobacco companies and to inhibit the promotion of user-generated pro-tobacco content would reduce youths’ exposure to pro-tobacco messaging online. Finally, as Ma and colleagues reported that 71% of youth reported recent exposure to anti-tobacco messaging,¹ there is still room for public health organisations to act in the meantime. Implementation of counter-marketing campaigns targeted to young people—deployed online and via other media sources—could dampen the effects of pro-tobacco messaging exposures in this vulnerable population.