Young Adults’ Exposure to and Engagement With Tobacco-Related Social Media Content and Subsequent Tobacco Use

Erin A Vogel; Jessica L Barrington-Trimis; Julia Vassey; Daniel Soto; Jennifer B Unger

doi:10.1093/ntr/ntad108

. 2024 Feb 15;26(Suppl 1):S3–S12. doi: 10.1093/ntr/ntad108

Young Adults’ Exposure to and Engagement With Tobacco-Related Social Media Content and Subsequent Tobacco Use

Erin A Vogel ^1,^2,^✉, Jessica L Barrington-Trimis ^3,⁴, Julia Vassey ⁵, Daniel Soto ^6,⁷, Jennifer B Unger ^8,⁹

PMCID: PMC10873498 PMID: 38366337

Abstract

Introduction

Nicotine/tobacco social media content may increase young people’s risk for use. This study examined prospective associations between exposure to and engagement with nicotine/tobacco-related social media content and nicotine/tobacco use among young adults.

Aims and Methods

Young adults (N = 2080) originally recruited from Southern California high schools for a prospective cohort study reported frequency of viewing and posting nicotine/tobacco content on four social media platforms (Facebook, Instagram, Twitter, and YouTube). Participants also reported frequency of seeing nicotine/tobacco posts from friends, seeing nicotine/tobacco posts from influencers or celebrities, and liking nicotine/tobacco posts. Within subsamples of nicotine/tobacco never users (n = 794), past users (n = 897) and current users (n = 389), analyses examined associations of baseline (May–October 2020) social media content exposure and engagement with follow-up (January–June 2021) tobacco use initiation (among never users), resumption (among past users), and continuation (among current users), adjusting for sociodemographic and socioenvironmental characteristics.

Results

Never users who saw nicotine/tobacco posts from friends (Adjusted Odds Ratio [AOR] = 2.91 [95% Confidence Interval [CI]: 1.46, 5.82], p = .002) or from celebrities or influencers (AOR = 2.77 [1.32, 5.84], p = .007) were significantly more likely to initiate nicotine/tobacco use than their peers. Among past users, posting nicotine/tobacco content at baseline was associated with use resumption (AOR = 1.77 [1.12, 2.80], p = .014). Content exposure and engagement were not associated with nicotine/tobacco use continuation among current users (p-values > .05).

Conclusions

Seeing nicotine/tobacco posts from friends, influencers, or celebrities was associated with greater odds of tobacco use initiation, but not resumption or continuation, 6 months later. Young adults with past nicotine/tobacco use who post about nicotine/tobacco may be at elevated risk for resuming use.

Implications

Young adults with exposure to nicotine/tobacco social media content were more likely than their peers to initiate nicotine/tobacco use 6 months later. Past nicotine/tobacco users who reported posting about nicotine/tobacco on social media at baseline were more likely than their peers to resume nicotine/tobacco use. Among young adults with current nicotine/tobacco use at baseline, social media activity did not predict odds of nicotine/tobacco use continuation at follow-up. Nicotine/tobacco content on social media should be restricted to reduce young people’s chances of nicotine/tobacco use initiation or resumption.

INTRODUCTION

Advertising exerts a strong influence on young people’s risk for tobacco use.¹ The 1998 Master Settlement Agreement restricted tobacco companies from marketing specifically to youth and from advertising in outdoor venues, a landmark settlement that nonetheless left loopholes that the industry exploited.² In 2009, the Family Smoking Prevention and Tobacco Control Act gave the U.S. Food and Drug Administration further authority to restrict cigarette advertising in youth-friendly venues and media outlets.³ Since then, the landscapes of both advertising and nicotine/tobacco product use have changed. Nicotine vaping products are now the most popular nicotine/tobacco products among adolescents⁴ and young adults.⁵ Concurrently, social media use has become nearly ubiquitous among young people, such that 91.5% of U.S. middle and high school students⁴ and 84% of U.S. young adults⁶ reported social media use in 2021. On social media, young people are exposed to content promoting and glamorizing nicotine/tobacco use, especially vaping. Nicotine vaping products are marketed on social media using youth-friendly tactics such as cartoons, young spokespeople, and aspirational identity themes.^7–9 Viewing glamorized nicotine/tobacco-related content may increase young people’s risk of initiating nicotine/tobacco use. Understanding young people’s exposure to nicotine/tobacco content on social media is an important step toward regulating harmful content, increasing young people’s resilience against the effects of harmful content, preventing nicotine/tobacco use initiation, and supporting cessation.

Nicotine/tobacco-related social media content is prevalent. Content analyses conducted throughout the 2010s have identified a preponderance of pro-vaping content on Instagram^10–12 and Twitter,^13,14 and engagement with e-cigarette Instagram content grew from 2017 to 2019.¹⁵ Twitter content related to the popular nicotine vaping device JUUL increased rapidly as the brand gained popularity among youth (2017–2018) and persisted even after JUUL shut down its Facebook and Instagram accounts in 2018.¹⁶ E-cigarette marketing on social media utilizes celebrities and influencers (ie, individuals with a large social media following who are thought to influence trends and are often compensated for promoting products^17,18).¹⁹ Underage adolescents and young adults, who cannot legally purchase tobacco products in the United States, have followed pro-vaping social media content, Instagram influencers who promote vaping products¹⁵ and JUUL’s Twitter account.²⁰ Moreover, vaping products are sold on popular social media sites such as Instagram²¹ and TikTok,²² with inadequate age-gating mechanisms to prevent sales to youth.²¹ Some popular vaping product companies’ official YouTube channels feature videos discouraging youth vaping, but also feature instructional and promotional videos and youth-friendly product characteristics such as flavors.²³ Online advertisements depicting flavored products are more attention-catching and result in greater product liking and use intentions compared to those depicting nonflavored products.²⁴ Vaping content appears to be evolving alongside youth’s product preferences and social media preferences. In 2020, the most popular Puff Bar videos on TikTok²⁵ and videos trivializing nicotine addiction²⁶ were viewed millions of times.

Cigars and cigarillos are also promoted and discussed on Instagram and Twitter.^27–29 Cigars, little cigars, and cigarillos comprise the most commonly used tobacco product category among black high school students in the United States³⁰ and are often promoted on Instagram by influencers of color.²⁸ Instagram content featuring cigarillos often depicts the making or use of blunts (ie, hollowed-out cigars, little cigars, or cigarillos filled with cannabis), which may facilitate cannabis use among youth who use cigar products.³¹ Exposure to nicotine/tobacco-related content on social media may affect a large proportion of young people. Among middle and high school students who use social media, 73.5% reported having ever seen vaping content in 2021.⁴ Engagement with nicotine/tobacco content has increased over time,³² and is greater among youth from several minoritized populations (ie, sexual and gender minority youth, Black youth, and Hispanic youth) than from the general population.³³

Exposure to and engagement with nicotine/tobacco content are associated with nicotine/tobacco use in cross-sectional studies.^34–37 Additionally, an experimental study of adolescents in California suggested a causal relationship between viewing vaping content and having more positive attitudes toward vaping and greater intentions to vape.³⁸ The glamorization of nicotine/tobacco on social media may facilitate use. In a nationally representative study, adolescents who used social media for self-expression and social learning had more frequent Instagram and Snapchat use, greater exposure to vaping-related content on Instagram and Snapchat, and more positive attitudes toward vaping.³⁹ Longitudinal studies have suggested that viewing nicotine/tobacco-related content increases susceptibility to vaping and other nicotine/tobacco product use.^40–44 Cohort studies of adolescents and young adults have found that exposure to nicotine/tobacco advertising on social media was significantly associated with subsequent nicotine/tobacco use.^29,40,41 Some evidence suggests that outcome expectancies, such as a belief that nicotine/tobacco will help regulate mood, may partially explain the associations between social media content exposure and engagement and subsequent nicotine/tobacco use.⁴²

A systematic review and meta-analysis concluded that exposure to tobacco-related content on social media is associated with tobacco use⁴⁵; however, changes in nicotine/tobacco products and social media platforms necessitate ongoing research with diverse samples of participants. Previous longitudinal studies focused primarily on vaping and were limited to current students, who are less likely to use tobacco than adolescents who left high school⁴⁶ or young adults not attending college.⁴⁷ Student samples are prone to selection bias,⁴⁸ and replication in a sample not limited to students would be informative. Engagement with nicotine/tobacco content needs to be measured in addition to exposure. Engagement with persuasive messaging is associated with increased message effectiveness⁴⁹ and engagement may proliferate nicotine/tobacco content (ie, through posting or sharing). Several studies examined prospective associations of tobacco content exposure and engagement with tobacco use among youth in the nationally representative Population Assessment of Tobacco and Health (PATH) Study.^43,44,50 However, data in these studies were collected in 2013–2016, prior to major national changes in nicotine and tobacco product availability and social media platform features. Nicotine vaping advertisement expenditures increased from 2016 to 2019,⁵¹ coinciding with the rise in nicotine vaping prevalence among young adults.⁴⁷ As nicotine vaping became more prevalent and more mainstream, more young people may have been exposed to vaping content posted by their friends, influencers, and celebrities.

Lastly, previous longitudinal research did not distinguish between different sources of nicotine/tobacco content (eg, friends, influencers, celebrities). Exposure variables in PATH data analyses were limited to: (1) seeing tobacco content on social media; (2) posting content, “liking” or following tobacco brands on social media; and (3) sending links about tobacco products on social media.^43,44 Other studies have measured whether young people saw nicotine vaping product posts and nicotine vaping product ads,^40–42 and one study measured engagement in both pro-tobacco and anti-tobacco social media activity (eg, “liking” or following brands, discouraging other people from using tobacco). Nicotine/tobacco content from different sources may have different effects. Young adults do not always view nicotine/tobacco influencers as advertising products, especially when the influencer’s relationship with the brand is not clearly disclosed. Vaping content clearly labeled as “sponsored” is more likely to be perceived as advertising and is less engaging than content that is not clearly sponsored.⁵² Perceived authenticity of influencers’ and celebrities’ posts could contribute to the association between exposure to nicotine/tobacco content and nicotine/tobacco product use.²⁹ Although the association between nicotine/tobacco advertising on social media and risk for nicotine/tobacco use is well-established, less is known about the impact of seeing content from friends versus influencers and celebrities.

The present study examined prospective associations between exposure to and engagement with nicotine/tobacco-related social media content and nicotine/tobacco use initiation and continuation among young adults participating in a prospective cohort study. Measurement of young adults’ exposure to nicotine/tobacco content distinguished between seeing friends’ posts and seeing posts from influencers or celebrities. This study examined prevalence of self-reported exposure to and engagement with nicotine/tobacco-related social media content and its prospective association with nicotine/tobacco use initiation (among baseline never users), resumption (among baseline past users), and continuation (among baseline current users) at follow-up. We hypothesized that exposure to and engagement with nicotine/tobacco content from any source at baseline would be associated with greater odds of initiation, resumption, and continuation at follow-up, and we explored different sources of content exposure (friends vs. influencers and celebrities) separately.

METHODS

Participants and Procedure

Data were drawn from the Happiness & Health Study, a prospective cohort study of young adults first recruited in ninth grade in 2013 from 10 participating public high schools in Los Angeles County.⁵³ Of the 4100 eligible students, 3396 provided assent and parental consent to enroll in the cohort. In-class surveys were administered semiannually from 2013 to 2017. After graduation, semiannual surveys were administered online. For the present study, the baseline survey (N = 2437) was administered May 18, 2020 through October 19, 2020, and the follow-up survey (N = 2207) was administered January 7, 2021 through June 9, 2021. The 2020 wave was chosen as the baseline wave for this analysis because it was the first wave in which participants were surveyed in detail about nicotine/tobacco content exposure. Participants were compensated $60 for each completed survey.

Measures

Social Media Use

At baseline, participants reported frequency of use of four social media platforms: Facebook, Instagram, Twitter, and YouTube (several times a day, daily, weekly, monthly or less, I do not use this form of social media, don’t know). Use frequency was recoded into ever-use (yes: several times a day, daily, weekly, monthly or less; no: I do not use this form of social media, don’t know) for each of the four platforms separately.

Exposure to and Engagement With Nicotine/Tobacco Content on Social Media

At baseline, 13 items measured exposure to and engagement with nicotine/tobacco content. Eight items measured frequency of: (1) seeing a post about tobacco or nicotine products, and (2) posting about tobacco or nicotine products (“several times a day,” “daily,” “weekly,” “monthly or less,” “I do not do this activity,” and “don’t know”) on each of four social media platforms (Facebook, Instagram, Twitter, and YouTube) among those who reported using the platform. A “no use of the platform” category was added. We then coded exposure to (yes/no) and engagement with (yes/no) nicotine/tobacco content on each platform (“yes” = monthly or less to several times a day; “no” = “I do not do this activity,” “don’t know,” or “no use of the platform”). Based on the platform-specific variables, we coded exposure to (yes/no) and engagement with (yes/no) nicotine/tobacco content on one or more platforms. A principal components analysis with Varimax rotation showed that the exposure and engagement variables for each platform loaded on a single component. Therefore, exposure to (engagement with) any platform was coded as “yes”; no exposure to (engagement with) nicotine/tobacco content on any platform was coded as “no.” Participants with no reported exposure to (engagement with) nicotine/tobacco content on any platform and those who were missing data on any platform were coded as missing.

Across all social media platforms, three items measured frequency of: (1) seeing a post from friends about tobacco or nicotine products, (2) seeing posts from celebrities or “influencers” about tobacco or nicotine products, and (3) liking posts about tobacco or nicotine products (several times a day, daily, weekly, monthly or less, don’t know). Items were recoded into “yes” (several times a day, daily, or weekly) or “no” (monthly or less or don’t know).

Nicotine/Tobacco Use

At baseline and follow-up, participants reported ever-use (yes/no) and past 30-day use (0, 1–2, 3–5, 6–9, 10–19, 20–29, or all 30 days) of seven nicotine/tobacco products (cigarettes, e-cigarettes, cigars, little cigars or cigarillos, hookah, IOQS or other heated tobacco product, snus, and nicotine pouches). Based on observed frequencies, baseline nicotine/tobacco use was coded as “never use,” “past use” (ever-use, but no use in the past 30 days), and “current use” (use in the past 30 days). Among baseline never users, nicotine/tobacco use initiation at follow-up was indicated by reporting any lifetime nicotine/tobacco product use. Among baseline past users, nicotine/tobacco use resumption was indicated by reporting any past-month nicotine/tobacco product use. Lastly, among baseline current users, nicotine/tobacco use continuation at follow-up was indicated by reporting any past-month nicotine/tobacco product use. Nicotine/tobacco product use was dichotomized as use versus no use, rather than number of days of use, due to observed frequencies and potential use of multiple products on the same day.

Participant Characteristics

At baseline, participants reported their gender (categorized as female, male, another gender), race and ethnicity (categorized as Hispanic, Asian, non-Hispanic White, another race [includes American Indian/Alaska Native, Black or African American, Native Hawaiian/Pacific Islander, other, multiethnic, or multiracial]), personal financial situation (categorized as living comfortably or meeting needs with a little left versus just meeting or not meeting basic expenses), and sexual identity (categorized as heterosexual or another sexual identity [includes asexual, bisexual, gay, lesbian, pansexual, queer, questioning or unsure, another identity not listed]). Two items measured how many of participants’ five closest friends use cigarettes and e-cigarettes (0, 1, 2, 3, 4, or 5 friends). Participants also reported past-month use of other substances besides nicotine/tobacco: alcohol, cannabis (ie, any past-month use of marijuana, electronic marijuana, marijuana edibles, dabbing, synthetic marijuana, and/or marijuana concentrates), and other substances (ie, any past-month use of prescription stimulants, prescription painkillers, prescription sedatives, heroin, or other drugs).

Statistical Analysis

First, descriptive statistics were examined for exposure to and engagement with nicotine/tobacco content on social media in the full sample. Second, participants were categorized as baseline nicotine/tobacco never users, past users, or current users. Among never users, five logistic regression models tested associations of baseline social media exposure and engagement (viewing any nicotine/tobacco content, posting any nicotine/tobacco content, seeing nicotine/tobacco posts from friends, seeing nicotine/tobacco posts from celebrities or influencers, liking nicotine/tobacco content) with nicotine/tobacco use initiation at follow-up. Among past (current) users, five logistic regression models tested associations of exposure to and engagement with nicotine/tobacco content at baseline with nicotine/tobacco use resumption (continuation) at follow-up (ie, past-month use). As a sensitivity analysis, five additional models restricted past-month use to participants reporting 3+ days of use at baseline, to differentiate repeated users from experimenters. Regression models adjusted for participant characteristics that were significantly associated with past-month nicotine/tobacco use at follow-up (ie, gender, sexual identity, personal finances, friends’ use of cigarette and/or e-cigarettes, past-month alcohol use, and past-month cannabis use).

RESULTS

The analytic sample consisted of 2080 participants. Among the 2437 participants who started the baseline survey, 77 were excluded for not reporting whether they used the four social media platforms measured, and an additional 280 were excluded for not reporting their nicotine/tobacco use status at follow-up. Participant characteristics are reported in Table 1. Because all participants were recruited in ninth grade in Fall 2013, there was minimal age variation (M = 21.2, SD = 0.4; range = 20–23). The sample was 59.0% female (37.6% male, 3.4% another or unreported gender), 76.5% heterosexual (21.1% another sexual identity), and 55.4% Hispanic (18.1% Asian, 10.9% non-Hispanic White, 14.9% another race, or multiple races). Most participants reported their financial situation as living comfortably (44.7%) or meeting needs with a little left (30.4%). At baseline, 794 (38.2%) had never used nicotine, 897 (43.1%) had used nicotine in the past but not currently, and 389 (18.7%) had used nicotine in the past month. The nicotine/tobacco products most frequently used in the past 30 days at baseline were e-cigarettes (78.9% of past-month nicotine/tobacco users), cigarettes (34.7%), and cigarillos (9.5%). Most participants (56.6%) reported drinking alcohol in the past month; 34.5% had used cannabis, and 5.6% had used other substances.

Table 1.

Participant Characteristics (N = 2080)

	% (n) or M (SD)
Age (M/SD)	21.2 (0.4)
Gender
Female	59.0% (1228)
Male	37.6% (782)
Another or unreported gender^a	3.4% (70)
Race/ethnicity
Hispanic	55.4% (1153)
Asian	18.1% (377)
White	10.9% (227)
Another or multiple^b	14.9% (309)
Not reported	0.7% (14)
Sexual identity
Heterosexual	76.5% (1592)
Another sexual identity^c	21.1% (438)
Not reported	2.4% (50)
Financial situation
Live comfortably	44.7% (929)
Meet needs with a little left	30.4% (632)
Just meet or don’t meet basic expenses	24.0% (500)
Not reported	0.9% (19)
Past-month substance use
Alcohol	56.6% (1171)
Cannabis^e	34.5% (718)
Other substances^f	5.6% (116)

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^aIncludes transgender male, transgender female, gender variant/nonbinary, and additional gender category/identity.

^bIncludes American Indian/Alaska Native, black or African American, Native Hawaiian/Pacific Islander, other, multiethnic, or multiracial.

^cIncludes asexual, bisexual, gay, lesbian, pansexual, queer, questioning or unsure, and another identity not listed.

^dIncludes marijuana, electronic marijuana, marijuana edibles, dabbing, synthetic marijuana, and marijuana concentrates.

^eIncludes prescription stimulants, prescription painkillers, prescription sedatives, heroin, and other drugs.

Exposure to and Engagement With Nicotine/Tobacco Content at Baseline

Exposure to and engagement with nicotine/tobacco content are reported in Table 2. Across platforms, 32.6% reported exposure to nicotine/tobacco content and 14.2% reported engagement with nicotine/tobacco content. Exposure was most prevalent on Instagram (21.6%), followed by YouTube (21.0%), Twitter (17.1%), and Facebook (11.2%). Engagement was less prevalent than exposure, and was also more prevalent on Instagram (10.2%) than the other platforms. As expected, participants with current nicotine/tobacco use were more likely to report exposure to and engagement with nicotine/tobacco content than were past users, with never users least likely to report exposure and engagement (p-values < .001; Supplementary Table 1). Seeing posts from friends (25.9%) at least weekly was more prevalent than seeing posts from celebrities or influencers (18.5%) or “liking” nicotine/tobacco content (15.7%).

Table 2.

Exposure to and Engagement With Tobacco Content at Baseline

	Several times a day	Daily	Weekly	Monthly or less	I do not do this activity	No use of the platform	Don’t know	Any activity^a (n/% yes)
Exposure^b
Facebook	31 (1.5%)	24 (1.2%)	45 (2.2%)	133 (6.4%)	724 (34.8%)	916 (44.0%)	204 (9.8%)	233 (11.2%)
Instagram	52 (2.5%)	72 (3.5%)	95 (4.6%)	231 (11.1%)	1189 (57.2%)	194 (9.3%)	238 (11.4%)	450 (21.6%)
Twitter	46 (2.2%)	50 (2.4%)	89 (4.3%)	170 (8.2%)	895 (43.0%)	685 (32.9%)	136 (6.5%)	355 (17.1%)
YouTube	51 (2.5%)	58 (2.8%)	95 (4.6%)	232 (11.2%)	1311 (63.0%)	124 (6.0%)	199 (9.6%)	436 (21.0%)
Any exposure^c								679 (32.6%)
Engagement^d
Facebook	17 (0.8%)	19 (0.9%)	16 (0.8%)	66 (3.2%)	914 (43.9%)	916 (44.0%)	126 (6.1%)	118 (5.7%)
Instagram	28 (1.3%)	34 (1.6%)	40 (1.9%)	111 (5.3%)	1510 (72.6%)	194 (9.3%)	154 (7.4%)	213 (10.2%)
Twitter	28 (1.3%)	32 (1.5%)	35 (1.7%)	93 (4.5%)	1077 (51.8%)	685 (32.9%)	120 (5.8%)	188 (9.0%)
YouTube	25 (1.2%)	22 (1.1%)	29 (1.4%)	95 (4.6%)	1632 (78.5%)	124 (6.0%)	145 (7.0%)	171 (8.2%)
Any engagement^c								295 (14.2%)
Source-specific exposure and passive engagement
See posts from friends	223 (10.7%)	118 (5.7%)	198 (9.5%)	698 (33.6%)	–	–	811 (39.0%)	539 (25.9%)
See posts from celebrities	230 (11.1%)	57 (2.7%)	98 (4.7%)	675 (32.5%)	–	–	991 (47.6%)	385 (18.5%)
“Like” posts	254 (12.2%)	30 (1.4%)	42 (2.0%)	612 (29.4%)	–	–	1105 (53.1%)	326 (15.7%)

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Percentages are of valid cases. Missing data were minimal (0.1%–1.8%).

^aDefined as responding “monthly or less,” “weekly,” “daily,” or “several times a day” for exposure and engagement; defined as “several times a day,” “daily,” or “weekly” for source-specific exposure and passive engagement.

^bDefined as seeing a nicotine/tobacco post on the platform.

^cDefined as responding “monthly or less,” “weekly,” “daily,” or “several times a day” on one or more of the platforms.

^dDefined as posting about nicotine/tobacco on the platform.

Nicotine/Tobacco Use at Follow-up

Table 3 presents associations of baseline nicotine/tobacco content exposure and engagement with nicotine/tobacco use initiation at follow-up among baseline never users. Odds of nicotine/tobacco use initiation did not differ between participants who had and had not viewed (p = .240) or posted (p = .339) nicotine/tobacco content, as measured on individual platforms. However, participants who had seen nicotine/tobacco posts from friends (AOR = 2.91 [95% CI: 1.46, 5.82], p = .002) or seen nicotine/tobacco posts from celebrities or influencers (AOR = 2.77 [95% CI: 1.32, 5.84], p = .007) were significantly more likely than their peers to have initiated nicotine/tobacco use at follow-up. “Liking” nicotine/tobacco posts was marginally significantly associated with initiation (AOR = 2.22 [95% CI: 0.99, 5.01], p = .054). Table 4 presents associations of baseline nicotine/tobacco content exposure and engagement with nicotine/tobacco use resumption among baseline past users. Posting about nicotine/tobacco at baseline was associated with resumption of use (AOR = 1.77, 95% CI [1.12, 2.80], p = .014); otherwise, social media content exposure and engagement were not significantly associated with nicotine/tobacco use resumption (p-values > .05). Table 5 presents associations of baseline nicotine/tobacco content exposure and engagement with past-month nicotine/tobacco use at follow-up among baseline current nicotine/tobacco users. Exposure to and engagement with nicotine/tobacco content were not associated with past-month nicotine/tobacco use at follow-up (p-values > .05).

Table 3.

Associations of Baseline Nicotine/Tobacco Content Exposure and Engagement With Tobacco Use Initiation at Follow-up Among Baseline Nicotine/Tobacco Never Users (n = 794)

	Initiated use at follow-up (n/%)			OR (95% CI)	p	AOR (95% CI)^a	p
		No	Yes
Viewed tobacco or nicotine content at baseline	No	538 (94.6%)	31 (5.4%)	.83 (.40, 1.72)	.618	.62 (.28, 1.37)	.240
Viewed tobacco or nicotine content at baseline	Yes	209 (95.4%)	10 (4.6%)	.83 (.40, 1.72)	.618	.62 (.28, 1.37)	.240
		No	Yes
Posted tobacco or nicotine content at baseline	No	679 (94.7%)	38 (5.3%)	.79 (.24, 2.62)	.698	.54 (.16, 1.90)	.339
Posted tobacco or nicotine content at baseline	Yes	68 (95.8%)	3 (4.2%)	.79 (.24, 2.62)	.698	.54 (.16, 1.90)	.339
		No	Yes
Saw posts from friends about tobacco or nicotine products at baseline	No	611 (96.2%)	24 (3.8%)	3.28 (1.71, 6.28)	<.001	2.91 (1.46, 5.82)	.002
	Yes	132 (88.6%)	17 (11.4%)	3.28 (1.71, 6.28)	<.001	2.91 (1.46, 5.82)	.002
		No	Yes
Saw posts from celebrities or “influencers” about tobacco or nicotine products at baseline	No	656 (95.9%)	28 (4.1%)	3.35 (1.67, 6.70)	<.001	2.77 (1.32, 5.84)	.007
	Yes	91 (87.5%)	13 (12.5%)	3.35 (1.67, 6.70)	<.001	2.77 (1.32, 5.84)	.007
		No	Yes
Liked posts about tobacco or nicotine products at baseline	No	670 (95.6%)	31 (4.4%)	2.88 (1.36, 6.11)	.006	2.22 (0.99, 5.01)	.054
Liked posts about tobacco or nicotine products at baseline	Yes	75 (88.2%)	10 (11.8%)	2.88 (1.36, 6.11)	.006	2.22 (0.99, 5.01)	.054

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^aAdjusted for participant gender, sexual identity, personal finances, friends’ use of cigarettes and/or e-cigarettes, past-month alcohol use, and past-month cannabis use (all significantly associated with nicotine/tobacco use at follow-up in bivariate analyses; p < .05).

Table 4.

Associations of Baseline Nicotine/Tobacco Content Exposure and Engagement With Past-Month Nicotine/Tobacco Use Resumption Among Baseline Nicotine/Tobacco Past Users (n = 897)

	Past-month use at follow-up (n/%)			OR (95% CI)	p	AOR (95% CI)^a	p
		No	Yes
Viewed tobacco or nicotine content at baseline	No	519 (86.4%)	82 (13.6%)	1.38 (.95, 2.02)	.094	1.31 (.88, 1.94)	.179
Viewed tobacco or nicotine content at baseline	Yes	238 (82.1%)	52 (17.9%)	1.38 (.95, 2.02)	.094	1.31 (.88, 1.94)	.179
		No	Yes
Posted tobacco or nicotine content at baseline	No	650 (86.3%)	103 (13.7%)	1.98 (1.27, 3.09)	.002	1.77 (1.12, 2.80)	.014
Posted tobacco or nicotine content at baseline	Yes	105 (76.1%)	33 (23.9%)	1.98 (1.27, 3.09)	.002	1.77 (1.12, 2.80)	.014
		No	Yes
Saw posts from friends about tobacco or nicotine products at baseline	No	524 (84.8%)	94 (15.2%)	1.04 (.70, 1.55)	.851	1.03 (.68, 1.56)	.874
	Yes	220 (84.3%)	41 (15.7%)	1.04 (.70, 1.55)	.851	1.03 (.68, 1.56)	.874
		No	Yes
Saw posts from celebrities or “influencers” about tobacco or nicotine products at baseline	No	578 (84.1%)	109 (15.9%)	.80 (.50, 1.28)	.346	.79 (.49, 1.29)	.348
	Yes	166 (86.9%)	25 (13.1%)	.80 (.50, 1.28)	.346	.79 (.49, 1.29)	.348
		No	Yes
Liked posts about tobacco or nicotine products at baseline	No	597 (84.4%)	110 (15.6%)	.86 (.53, 1.40)	.545	.86 (.52, 1.43)	.561
Liked posts about tobacco or nicotine products at baseline	Yes	145 (86.3%)	23 (13.7%)	.86 (.53, 1.40)	.545	.86 (.52, 1.43)	.561

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^aAdjusted for participant gender, sexual identity, personal finances, friends’ use of cigarettes and/or e-cigarettes, past-month alcohol use, and past-month cannabis use (all significantly associated with past-month nicotine/tobacco use at follow-up in bivariate analyses; p < .05).

Table 5.

Associations of Baseline Nicotine/Tobacco Content Exposure and Engagement With Past-Month Nicotine/Tobacco Use Among Baseline Nicotine/Tobacco Current Users (n = 389)

	Past-month use at follow-up (n/%)			OR (95% CI)	p	AOR (95% CI)^a	p
		No	Yes
Viewed tobacco or nicotine content at baseline	No	78 (35.8%)	140 (64.2%)	1.50 (.97, 2.33)	.068	1.54 (.98, 2.42)	.064
Viewed tobacco or nicotine content at baseline	Yes	46 (27.1%)	124 (72.9%)	1.50 (.97, 2.33)	.068	1.54 (.98, 2.42)	.064
		No	Yes
Posted tobacco or nicotine content at baseline	No	101 (33.6%)	200 (66.4%)	1.47 (.86, 2.52)	.163	1.42 (.82, 2.49)	.213
Posted tobacco or nicotine content at baseline	Yes	22 (25.6%)	64 (74.4%)	1.47 (.86, 2.52)	.163	1.42 (.82, 2.49)	.213
		No	Yes
Saw posts from friends about tobacco or nicotine products at baseline	No	84 (32.8%)	172 (67.2%)	1.17 (.74, 1.85)	.504	1.07 (.67, 1.73)	.777
	Yes	38 (29.5%)	91 (70.5%)	1.17 (.74, 1.85)	.504	1.07 (.67, 1.73)	.777
		No	Yes
Saw posts from celebrities or “influencers” about tobacco or nicotine products at baseline	No	90 (30.5%)	205 (69.5%)	.80 (.48, 1.31)	.368	.73 (.43, 1.22)	.226
	Yes	32 (35.6%)	58 (64.4%)	.80 (.48, 1.31)	.368	.73 (.43, 1.22)	.226
		No	Yes
Liked posts about tobacco or nicotine products at baseline	No	97 (31.4%)	212 (68.6%)	1.00 (.57, 1.72)	.985	.95 (.54, 1.70)	.874
Liked posts about tobacco or nicotine products at baseline	Yes	23 (31.5%)	50 (68.5%)	1.00 (.57, 1.72)	.985	.95 (.54, 1.70)	.874

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^aAdjusted for participant gender, sexual identity, personal finances, friends’ use of cigarettes and/or e-cigarettes, past-month alcohol use, and past-month cannabis use (all significantly associated with past-month nicotine/tobacco use at follow-up in bivariate analyses; p < .05).

We also ran several sensitivity analyses. When baseline current users were defined as those using repeatedly (ie, 3 or more days in the past month), participants who saw posts from celebrities or influencers at baseline were significantly less likely to report continued use (AOR = 0.52 [95% CI: .28,.99], p = .047) than those who did not. Otherwise, the pattern of results did not change. When the source-specific exposure (ie, seeing posts from friends, seeing posts from influencers or celebrities) and engagement (ie, “liking” posts) variables were treated as continuous predictors (0 = monthly or less or don’t know to 3 = several times a day) or as 3-level categorical predictors (0 = monthly or less or don’t know, 1 = weekly, 2 = daily or several times a day), the patterns of results also did not change.

DISCUSSION

Among young adults who had never used nicotine/tobacco products, exposure to nicotine/tobacco-related social media posts from friends, influencers, or celebrities was associated with greater odds of nicotine/tobacco use initiation 6 months later. Among those who had used nicotine/tobacco in the past, but not currently, those who posted about nicotine/tobacco on social media were more likely than their peers to resume nicotine/tobacco use at 6-month follow-up. Exposure to and engagement with nicotine/tobacco-related content were more prevalent among young adults who had used nicotine/tobacco than those who had not; however, they were not associated with nicotine/tobacco use continuation at 6-month follow-up. Results suggest that exposure to nicotine/tobacco-related social media content may increase young adults’ risk of initiating nicotine/tobacco use, and posting about nicotine/tobacco may suggest vulnerability to resuming nicotine/tobacco use.

While nicotine/tobacco use initiation has traditionally occurred mostly in adolescence, initiating nicotine/tobacco use in young adulthood is now common.^54,55 Like adolescents, young adults may be influenced to try nicotine/tobacco by their perceptions of peers’ use.⁵⁶ Seeing peers using nicotine/tobacco on social media may increase perceptions of nicotine/tobacco use as normative^38,39 and positive.^34,42 Social media may both glamorize and normalize nicotine/tobacco use.²² After adjusting for close friends’ nicotine/tobacco use, prospective associations between social media activity and nicotine/tobacco use initiation remained statistically significant, suggesting that the effects of seeing friends’ posts on social media extend beyond the effects of merely having friends who use nicotine/tobacco products. A previous experimental study of adolescents found that both peer-generated vaping content and social media advertisements increased adolescents’ positive perceptions of vaping.³⁸ Consistent with those results, seeing nicotine/tobacco posts from friends and from celebrities or influencers were both prospectively associated with vaping initiation. A previous longitudinal analysis of college students found that a belief in the affect-regulating effects of vaping facilitated the association between social media content exposure and vaping, even after accounting for nicotine/tobacco use in young adults’ offline social networks.⁴² Young adults who see nicotine/tobacco use portrayed on social media as a way to manage stress or to feel good may try nicotine/tobacco.

Seeing nicotine/tobacco content from friends and from influencers and celebrities were both associated with tobacco use initiation. Social networks are comprised mostly of weak ties. “Friends” on social media extend far beyond one’s close friends in real life, and can bridge different social circles.⁵⁷ Even if one’s own close friends do not use nicotine/tobacco, acquaintances may. Broad exposure to peers’ nicotine/tobacco use through social media may facilitate perceptions of nicotine/tobacco use as normative. Viewing influencers using nicotine/tobacco on social media may have had similar effects. When individuals perceive themselves to be close with an influencer or aspire to be similar to an influencer, the influencer’s social media content is likely to be engaging and to impact behavior.⁵⁸ Though celebrities often seem like distant figures, or ideals to which to aspire, social media can make celebrities seem more normal and accessible, similar to influencers. Celebrities’ social media interactions with their followers encourage a sense of closeness that in turn increases intention to behave similarly to the celebrity.⁵⁹ Friends, acquaintances, celebrities, and influencers alike may make tobacco use seem both glamorous and normative.

Among young adults with previous nicotine/tobacco use experience, social media content exposure was not associated with nicotine/tobacco use at follow-up, despite greater exposure to and engagement with nicotine/tobacco content among ever users than never users. Once initiated, young adults’ nicotine/tobacco use may be driven more by their own experience with nicotine/tobacco than peers’ experience. Nicotine/tobacco use often results in conditioned responses to nicotine/tobacco-related cues and development of dependence symptoms, which are powerful drivers of continued nicotine/tobacco use.⁶⁰ Social media algorithms are more likely to display nicotine/tobacco content to users than nonusers, resulting in greater exposure. However, nonusers also reported substantial exposure to nicotine/tobacco content; for example, 16.8% of nonusers reported seeing nicotine/tobacco content on Instagram. Young adults with and without current or past nicotine/tobacco use may have different reasons for viewing nicotine/tobacco social media content. Previous research with young adults has found that never users and past users were motivated by curiosity and incidental ad exposure, while current users engaged to receive discounts or because the advertised product looked appealing.⁶¹ Although content exposure was not associated with nicotine/tobacco use resumption or continuation, posting about nicotine/tobacco was prospectively associated with resuming nicotine/tobacco use. One’s social media posts can reflect their mental and behavioral health concerns, such as suicidal ideation⁶² and problematic cannabis use.⁶³ A young adult who posts about nicotine/tobacco use on social media may be at high risk of returning to nicotine/tobacco use, suggesting a need for intervention.

This study measured exposure to and engagement with nicotine/tobacco content in two different sets of survey items. The platform-specific exposure and engagement variables were composite variables derived from participants’ reports of seeing and posting about nicotine/tobacco products on each of four social media platforms: Facebook, Instagram, Twitter, and YouTube. The source-specific set directly queried participants about seeing posts from friends, seeing posts from celebrities or influencers, and “liking” posts. Prevalence of exposure and engagement were similar across both measures; however, platform-specific measures of exposure and engagement were not associated with tobacco use initiation at follow-up.

Limitations and Future Directions

This study had several limitations. First, ambiguities in some of the survey items may have affected participants’ responses. Participants may have underreported nicotine/tobacco content exposure in the platform-specific items if they were unable to remember on which platform(s) they saw nicotine/tobacco posts, or if they limited their definition of “tobacco content” to advertisements only. The source-specific items did not measure advertisement exposure and therefore were not comprehensive; however, they may have reminded participants of nicotine/tobacco content outside the bounds of traditional advertising (eg, influencers’ posts) and therefore captured content exposure not measured in the platform-specific items. The platform-specific items did not include all social media platforms. Participants who did not endorse seeing nicotine/tobacco content on Facebook, Instagram, Twitter, or YouTube may have seen nicotine/tobacco content on TikTok and therefore endorsed exposure in the source-specific items. Recent research has found that TikTok activity is strongly associated with nicotine/tobacco product use.²⁹ The valence of nicotine/tobacco content was not measured. “Liking” a post could indicate approval of nicotine/tobacco use if the post is pro-nicotine/tobacco, and disapproval of nicotine/tobacco use if the post contains an anti-nicotine/tobacco message. Results underscore the importance of measuring exposure to both pro-nicotine/tobacco and anti-nicotine/tobacco content across all platforms, sources (eg, peers, influencers, advertisements), and measuring content engagement across the spectrum of engagement behaviors (eg, “liking,” commenting, sharing, posting).

Second, all participants were originally recruited as high school students in Southern California in 2013. The sample may have been affected by attrition bias; however, the sample used in this analysis was still diverse in sociodemographic characteristics such as race/ethnicity and socioeconomic status. Third, causal inference regarding the associations between social media activity and tobacco use initiation is limited by the observational study design, and directionality is unclear. Young adults who were already susceptible to nicotine/tobacco use may have sought nicotine/tobacco social media content and therefore been more likely to initiate use at follow-up. Therefore, we cannot conclude that social media content exposure increases risk of nicotine/tobacco use. However, results are consistent with those of cross-sectional,^34–36 experimental³⁸ and other longitudinal studies,^40–44 and a recent meta-analysis.⁴⁵ Finally, analyses adjusted for sociodemographic characteristics and for offline exposure to peers’ nicotine/tobacco use. Nonetheless, unmeasured confounders may have affected both social media activity and tobacco use initiation.

Conclusions

Among young adults who had never used nicotine/tobacco, seeing and “liking” social media posts related to nicotine/tobacco were associated with greater odds of tobacco use initiation 6 months later. Young adults with past nicotine/tobacco use who posted about nicotine/tobacco on social media had greater odds of resuming nicotine/tobacco use than those who did not post about it. However, young adults with current nicotine/tobacco use who viewed and/or engaged with nicotine/tobacco use were not at elevated risk for continuing to use tobacco 6 months later. Exposure to social media content may have a stronger influence on nicotine/tobacco use initiation than resumption or continuation, while engagement—specifically, posting content—may indicate elevated risk for resuming nicotine/tobacco use. Nicotine/tobacco content on social media should be restricted to protect young people, who use social media frequently and are at high risk of tobacco use initiation.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

ntad108_suppl_Supplementary_Table_S1

Click here for additional data file.^{(15.9KB, docx)}

Supplement Sponsorship

This article appears as part of the Nicotine & Tobacco Research supplement titled “Advances in Social Media Research to Reduce Tobacco Use,” sponsored by the National Cancer Institute and the NIH Office of Disease Prevention.

Contributor Information

Erin A Vogel, Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, San Francisco, Los Angeles, CA, USA; Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA.

Jessica L Barrington-Trimis, Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, San Francisco, Los Angeles, CA, USA; Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA.

Julia Vassey, Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, San Francisco, Los Angeles, CA, USA.

Daniel Soto, Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, San Francisco, Los Angeles, CA, USA; Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA.

Jennifer B Unger, Department of Population and Public Health Sciences, University of Southern California Keck School of Medicine, San Francisco, Los Angeles, CA, USA; Institute for Addiction Science, University of Southern California, Los Angeles, CA, USA.

Funding

This work was supported by the National Cancer Institute (grant numbers R01CA229617 to JLB, R01CA260459 to JBU, U54CA180905, P30CA014089-47) and the National Institute on Drug Abuse (grant numbers K01DA042950 to JLB, K01DA055073 to EAV) of the National Institutes of Health.

Declaration of Interests

The authors have no competing interest to disclose.

Data Availability

Data are available upon reasonable request.

Author Contributions

EAV: Conceptualization, formal analysis, writing—original draft. JLB: Conceptualization, funding acquisition, project administration, supervision, writing—reviewing and editing. JV: Writing—reviewing and editing. DS: Writing—reviewing and editing. JBU: Conceptualization, funding acquisition, supervision, writing—reviewing and editing.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

ntad108_suppl_Supplementary_Table_S1

Click here for additional data file.^{(15.9KB, docx)}

Data Availability Statement

Data are available upon reasonable request.

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PERMALINK

Young Adults’ Exposure to and Engagement With Tobacco-Related Social Media Content and Subsequent Tobacco Use

Erin A Vogel, PhD

Jessica L Barrington-Trimis, PhD

Julia Vassey, MPH

Daniel Soto, EdD, MPH

Jennifer B Unger, PhD

Abstract

Introduction

Aims and Methods

Results

Conclusions

Implications

INTRODUCTION

METHODS

Participants and Procedure

Measures

Social Media Use

Exposure to and Engagement With Nicotine/Tobacco Content on Social Media

Nicotine/Tobacco Use

Participant Characteristics

Statistical Analysis

RESULTS

Table 1.

Exposure to and Engagement With Nicotine/Tobacco Content at Baseline

Table 2.

Nicotine/Tobacco Use at Follow-up

Table 3.

Table 4.

Table 5.

DISCUSSION

Limitations and Future Directions

Conclusions

Supplementary Material

Supplement Sponsorship

Contributor Information

Funding

Declaration of Interests

Data Availability

Author Contributions

REFERENCES

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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