Associations between health-related use of social media and positive lifestyle behaviors: Findings from a representative sample of US adult smokers

Abstract

Background:

Cigarette smokers have elevated cardiovascular risk factors, which contributes significantly to mortality. Although social media is a potential avenue to deliver smoking interventions, its role in health promotion among smokers remains relatively unexplored.

Objective:

To examine the uptake and impact of health-related social media use in cigarette smokers.

Methods:

Using data from the 2017–2020 Health Information National Trends Survey, we evaluated differences in health-related social media use between smokers and non-smokers. Multivariable logistic regression was performed to examine the association between social media use and positive health behaviors.

Results:

We included 1,863 current smokers and 13,560 non-smokers; Most participants were women (51.0%), White (64.6%), and 49.2% were aged ≥50 years. Smokers who used ≥1 social media site for health-related purposes in the past year were significantly more likely to meet the guideline recommendations for: i) weekly physical activity (AOR 2.00, 95% CI 1.23–3.24), ii) daily vegetable intake (AOR 2.48, 95% CI 1.10–5.59), and iii) weekly strength training (AOR 1.80, 95% CI 1.10–2.94). However, the odds of reporting intentions to quit smoking (AOR 1.81, 95% CI 0.98–3.34) and attempts at smoking cessation (AOR 1.68, 95% CI 0.90–3.12) did not differ by health-related social media use.

Conclusion:

Smokers use social media for health-related purposes at comparable rates to non-smokers. While our findings indicate that these platforms present a novel opportunity for health promotion among smokers, future research exploring the utility of social media in smoking cessation is crucial.

Introduction

Cigarette smoking remains a leading cause of preventable morbidity and mortality in the United States (U.S), despite aggressive and robust public health campaigns against smoking (1). Although the prevalence of U.S. adult smokers has decreased from 20.9% in 2005 to 12.5% in 2020, roughly 30.8 million adults still smoke (1). Multiple studies have shown that smokers experience a reduced life expectancy—at least 5 to 10 years shorter on average—compared with the general population(2–4). Overall mortality among U.S. smokers is about three times higher than among those who do not smoke cigarettes (5). Evidence suggests that this increased mortality is due to poor physical and cardiovascular health as a result of smoking-related diseases (5).

Cardiovascular diseases represent a significant health concern for smokers. Smoking not only contributes to the development of atherosclerosis and hypertension but is also intricately linked with other physical health behaviors, such as physical inactivity and unhealthy dietary choices, which further elevate the risk of cardiovascular diseases (6–9). Moreover, these behaviors tend to coexist and are often resistant to modification, presenting a challenge for individuals who aim to improve their cardiovascular health by altering multiple risk factors simultaneously.

While the health benefits of smoking cessation are substantial and include improved cardiorespiratory function, decreased risk of lung cancer, improved quality of life and well-being, and reduced premature mortality (10–13), data from the Centers of Disease Control (CDC) report that although most smokers are interested in quitting, fewer than 1 in 10 succeed annually (14). Despite the availability of therapies to aid smoking cessation, less than one-third of adult smokers in the United States use them to support their efforts at cessation (14). Even after smoking cessation, smokers remain at a persistently elevated risk of cardiovascular disease (15, 16) and mortality (17, 18). Thus, given the low rates of smoking cessation and significantly elevated morbidity and mortality associated with smoking in the U.S., further research into strategies for health promotion and improving the physical and cardiometabolic health of smokers is critical.

Social media has emerged as an important tool that can augment and improve health outcomes (19). For this study, social media is defined as digital platforms (i.e., websites, apps) that allow users to connect and interact with other users across the internet (20). A growing number of U.S. adults use social media, with the latest estimate in 2021 showing that 72% of U.S. adults use at least one social media site, compared to 5% of U.S. adults in 2005 (21). Similarly, there has been a rapid uptake, adoption, and integration of social media within healthcare (22–24). Patients use social media for self-management and to participate in online health support forums (25–27). Healthcare providers use social media for patient education, professional development, self-promotion, and research recruitment (28–30). Social media is also free for public consumption. Thus, social media affords a low-cost opportunity to reach a large audience and may influence health behavior by increasing health literacy and fostering social support among smokers.

However, it is not entirely clear if the use of social media is associated with health benefits among smokers. A review by Naslund et al. (2017) found that interventions for smoking cessation delivered through social media were feasible and readily acceptable by smokers. Another review (32) found equivocal results in the effect of social media interventions on smoking cessation. Although early evidence indicates that social media holds promise in improving the health of smokers, the efficacy of these tools in promoting positive lifestyle behaviors among smokers is yet to be proven. Further, current evidence on the impact of social media on health promotion among smokers has several limitations, including: 1) use of convenience samples and subpopulations of smokers that are already motivated to quit smoking; 2) lack of nationally representative data; 3) no studies examining the real-world impact of social media use among smokers in their daily life; and 4) a primary focus on smoking cessation outcomes, rather than general physical health behaviors (e.g. physical activity and diet) (31, 32). Therefore, research evaluating the association between health-related social media use with positive health behaviors, including smoking cessation, in smokers is needed but lacking.

Hence, the purpose of this study is to evaluate (i) the prevalence and use of social media among smokers, and (ii) the association between social media use with current health behaviors and self-reported intentions/attempts to quit smoking, using a large scale and nationally representative database of United States adults. Findings may offer useful insights into the relationship between social media use and healthy behavior adherence in smokers to guide the design and delivery of social media-based health interventions for smokers.

Materials and Methods

Data Sample

Cross-sectional data from the fifth iteration of the National Cancer Institute’s Health Information National Trends Survey (HINTS 5) was obtained for this study. HINTS is a nationally representative survey of the U.S. adult population conducted every 1–3 years since 2003, to collect data related to health information, health behaviors, cancer risk factors, and communication technology (33). The target sample for HINTS was non-institutionalized, civilian adults (aged ≥18 years) living in the U.S.

Data used in this study were obtained from four HINTS cycles comprising respondents from HINTS 5, cycles 1–4. Data collection periods were January-May 2017 (HINTS 5, cycle 1), January-May 2018 (HINTS 5, cycle 2), January-April 2019 (HINTS 5, cycle 3), and February-June 2020 (HINTS 5, cycle 4). HINTS 5 cycles 1, 2, and 4 were administered as a single-mode mailed survey. HINTS 5 cycle 3 used a mixed-mode collection of either mail or internet-based surveys. For cycle 1, 13,360 U.S. households received questionnaires and there were 3,285 responses, resulting in a response rate of 32.4%. For cycle 2, 14,585 U.S. households received questionnaires with 3,504 responses, resulting in a response rate of 32.9%. For cycle 3, 23,430 U.S. households received questionnaires and there were 5,438 responses, resulting in a response rate of 30.3%. For cycle 4, 15,347 U.S. households received questionnaires and there were 3,865 responses, resulting in a response rate of 36.7%. All iterations of HINTS 5 employed a two-stage, stratified random sampling technique. The first stage involved the selection of non-vacant residential addresses obtained from the Marketing Systems Group (MSG). In the second stage, an adult from each household was selected for participation in the survey using the ‘Next Birthday’ method. For HINTS 5, cycle 1, the database of residential addresses was grouped into three strata, including addresses in areas with high concentrations of minority populations; addresses in areas with low concentrations of minority populations; and addresses in counties comprising Central Appalachia, regardless of minority population. In HINTS 5, cycles 2, 3, and 4, two strata were used and included (1) addresses in areas with a high concentration of minority population, and (2) addresses in areas with a low concentration of minority population.

For this study, current smokers were ascertained from respondents who answered “yes” to the survey question “Have you smoked at least 100 cigarettes in your entire life?” and reported smoking “every day” or “some days” when asked: “Do you now smoke cigarettes every day, some days, or not at all?” (34). After combining all four HINTS iterations, the total sample comprised 16,092 respondents. Of the total sample, 269 (1.74%) and 400 (2.6%) participants were missing data for smoking and social media variables, respectively. These were excluded in the final analysis. Thus, the final eligible sample consisted of 15,423 respondents, of which approximately 1,863 were current smokers.

Measures

Exposure Variable

The main variable of interest was social media use among smokers within the past 12 months preceding the survey. We used information derived from survey items within HINTS 5, as follows:

• General social media use: responses to the question, “In the last 12 months, have you visited a social networking site such as Facebook or LinkedIn?”

• Health-related social media use: responses to the following survey questions: “In the last 12 months, (i) have you shared health information on social networking sites, such as Facebook or Twitter? (ii) have you participated in an online forum or support group for people with similar health or medical issues? and (iii) have you watched a health-related video on YouTube?”

The response options for all the question items were “yes” and “no,” and thus, were dichotomized. To investigate the association between health-related social media use and health promotion, we created a composite variable categorizing health-related social media use. Participants who endorsed at least one or more health-related social media use (i.e., sharing information, participating in online forums, and watching health videos on YouTube) were categorized as users (coded as 1), and those reporting no health-related social media use were characterized as non-users (coded as 0).

Outcomes

The primary outcomes of interest were whether participants reported achieving the nationally recommended levels of (i) general physical activity (≥ 150 minutes per week), (ii) strength and exercise training, and (iii) fruit and vegetable intake (≥ 2 cups of each, per day). Additionally, participants reported intentions to change smoking-related behaviors (intentions and attempts to quit smoking) in the past year.

General Physical Activity

Physical activity was ascertained using the following two questions: (i) “In a typical week, how many days do you do any physical activity or exercise of at least moderate intensity, such as brisk walking, bicycling at a regular pace, and swimming at a regular pace?” (8 response options ranging from none to 7 days per week) and (ii) “On the days that you do any physical activity or exercise of at least moderate intensity, how long do you do these activities?” (2 response options for minutes and hours). We then reclassified the response options into a single dichotomous outcome variable for physical activity that is, whether the subject (i) met physical activity recommendations (≥150 minutes per week) or (ii) did not meet the physical activity recommendations (<150 minutes per week) based on the Center for Disease Control (CDC) physical activity recommendations (35).

Strength/Resistance training

Respondents’ level of strength training was ascertained from the survey question, “In a typical week, outside of your job or work around the house, how many days do you do leisure-time physical activities specifically designed to strengthen your muscles?” Based on the CDC recommendation of 2 or more days a week of muscle-strengthening activities that work all major muscle groups, we reclassified the response options into a single dichotomous outcome variable for resistance strength training, that is, whether the subject (i) met resistance muscle-strengthening recommendations (≥2 days a week) or (ii) did not meet the resistance muscle-strengthening recommendations (<2 days a week) (35).

Fruit and Vegetable Intake

We assessed fruit and vegetable intake using two questions: (i) “About how many cups of fruit (including 100% pure fruit juice) do you eat or drink each day?” and (ii) “About how many cups of vegetables (including 100% pure vegetable juice) do you eat or drink each day?” Response options for each ranged from none to >4 cups per day. We then reclassified the response options for both questions into two separate dichotomous outcome variables, that is, the subject either (i) met recommendations for fruit (> 2 cups daily) or (ii) did not meet the recommendations for fruit intake and (iii) met recommendations for vegetables (>2 cups daily) or (iv) did not meet recommendations for vegetable intake based on the Center for Disease Control (CDC) Dietary Guidelines for Americans (Dietary Guidelines for Americans, 2020–2025, 37).

Intention and Attempt to Quit Smoking

Informed by previous research, (34) we ascertained smoking cessation intentions using the following survey question: “Are you seriously considering quitting smoking within the next 6 months?” Smoking cessation attempts were assessed using the following question: “At any time in the past year, have you stopped smoking for 1 day or longer because you were trying to quit?” Response options for both question items were “yes” and “no.” Responses of “yes” to both survey questions were considered intentions and attempts to quit smoking, respectively.

Participant characteristics

Sociodemographic and health-related variables included were age, gender, race, educational level, household income, access to a regular health provider, previous cancer diagnosis, body mass index, presence of comorbidities, and rural-urban residence. Gender was categorized as male or female. Age was categorized as 18–34, 35 to 49, 50 to 64 years, and 65 years or older. Race was categorized as White, Black or African American, Hispanic, and Other. Level of education was categorized as high school graduate or less, some college, and college graduate or postgraduate. Rural or urban residence was defined using the US Department of Agriculture’s (USDA) 2003 Rural-Urban Continuum Codes. Codes 1 to 3 were classified as urban, while codes 4 to 9 were classified as rural. Household annual income was categorized as less than $20k, $20k to less than 35k, $35k to less than 50k, and $50k to less than 75k, $75k or above. Body Mass Index was dichotomized into obese (BMI ≥ 30) and non-obese (BMI < 30). Respondents were classified as having a comorbidity if they had one or more of the following tobacco-related diseases: diabetes mellitus, hypertension, heart disease, previous cancer diagnosis, or lung disease.

Statistical Analysis

Data were analyzed using descriptive, bivariate, and multivariable analytic techniques. First, basic descriptive statistics using frequencies and percentages was conducted for the entire study sample and stratified by smoking status. Next, Pearson chi-squared tests of association were used to compare the proportions of health-related social media usage by sociodemographic and health factors among current smokers. Logistic regression analyses adjusting for age, gender, race, educational level, household income, access to a regular health provider, body mass index, presence of comorbidities, and rural-urban residence was conducted to evaluate the odds of health-related social media utilization between smokers and the general (non-smokers) population. Separate weighted multivariable logistic regression analyses adjusting for similar covariates was performed to investigate the association between health-related social media use and positive lifestyle behaviors (i.e., smoking cessation behaviors, meeting recommendations for physical activity, strength/exercise training, and diet) exclusively among smokers. All analyses were conducted using the “svy” command in Stata 17.0 statistical software (StataCorp LP, College Station, Texas, USA). Final person weights and jack-knife replicate weights provided within the HINTS 5 dataset were used to provide national estimates representative of the United States population. All tests were two-sided, and p values < 0.05 were considered statistically significant.

Results

Of the 16,092 respondents for HINTS 5 cycles 1 to 4, a total of 15,423 had provided data on smoking and social media use status and thus were eligible for inclusion in our study. Of those providing usable data, 1863 (14.2%; weighted %) were current smokers, and 13,560 (85.8%; weighted %) were non-smokers. Of the full sample, 51.0% were women, 64.6% were White, 49.2% were aged 50 years or more, 31.5% were college graduates or postgraduates, 28.5% reported annual income of less than USD 35,000, and 46.9% reported at least one comorbidity. Full details on the distribution of the sociodemographic characteristics of the study population by smoking status are shown in Table 1.

Table 1:

Sociodemographic/health characteristics by Smoking Status sample N = (15,423)

Demographic variables	Total (n=15,423), %	Non- Smokers (n=13,560), %	Smokers (n= 1,863), %	Test-Statistic	p-value
Gender				16.8	<0.001
Female	51.0	87.8	12.2
Male	49.0	83.8	16.2
Age Group				18.5	<0.001
18–34	24.2	88.9	11.1
35–49	26.6	81.8	18.2
50–64	29.9	83.0	17.0
65+	19.3	91.3	8.7
Education				53.7	<0.001
High school or less	30.4	80.0	20.0
Some college	38.1	84.0	16.0
College graduate or more	31.5	93.3	6.7
Household Income				27.6	<0.001
< $20,000	16.9	75.9	24.1
$20,000 – $34,999	11.6	80.0	20.0
$35,000 – $49,999	13.6	83.9	16.1
$50,000 – $74,999	18.3	85.8	14.2
$75,000 or more	39.6	91.8	8.2
Race				3.5	0.015
White	64.6	85.6	14.4
Black/African American	10.8	83.3	16.7
Hispanic	16.3	89.1	10.9
Others	8.3	88.0	12.0
Residence				3.3	0.069
Urban	86.6	86.2	13.8
Rural	13.4	83.6	14.4
Comorbidity				2.2	0.142
None	53.1	86.7	13.3
At least one	46.9	84.9	15.1
Regular Provider
No	35.3	83.3	16.7	10.2	0.002
Yes	64.7	87.2	12.8
Body Mass Index (BMI)
Non-obese (BMI < 30)	67.0	86.1	13.9	0.6	0.451
Obese (BMI > = 30)	33.0	85.3	14.7

In bivariate analysis (Table 1), current smokers were more likely to be men (16.2%) vs. women (12.2%), high school graduates (20.0%) vs. people with a college education (6.7%), people with low income (24.1% were from households with annual income ≤ US$20,000) vs. people with higher income (8.2% were from households with annual income ≥ US $75,000), and people without access to a regular provider (16.7%) vs. people with access to a regular provider (12.8%).

In the bivariate analysis (Table 2), current smokers who reported at least one or more health-related social media use were more likely to be younger adults aged 18 to 34 years (58.1%) vs. older adults aged >65 years (15.6%), college graduates (42.8%) vs. people with high school or lesser education (26.8%). Smokers who were obese (43.7% vs. 33.5%), and those who had access to a regular provider (41.0% vs. 31.8%) were more likely to have reported using social media for health-related purposes. However, health-related social media use among smokers did not differ significantly by race, gender, presence of comorbidities, income, or geographical location.

Table 2:

Bivariate association of sociodemographic and health-related characteristics by social media utilization status among smokers N = (1,863)

Demographic variables	Total (n=1,863), %	Social Media Non-User (n=1,225), %	Social Media User (n= 638), %	Test-Statistic	p-value
Gender				0.9	0.337
Female	44.0	60.7	39.3
Male	56.0	64.7	35.3
Age Group				15.3	<0.001
18–34	28.7	41.9	58.1
35–49	33.9	57.7	42.3
50–64	35.6	72.2	27.8
65+	11.8	84.4	15.6
Education				10.7	<0.001
High school or less	42.6	73.2	26.8
Some college	42.6	55.3	44.7
College graduate or more	14.8	57.2	42.8
Household Income				1.7	0.143
< $20,000	28.2	70.1	29.9
$20,000 – $34,999	16.0	56.3	43.7
$35,000 – $49,999	15.2	61.0	39.0
$50,000 – $74,999	18.0	66.2	33.8
$75,000 or more	22.6	56.6	43.4
Race				1.1	0.357
White	67.0	65.0	35.0
Black/African American	12.9	62.7	37.3
Hispanic	12.9	57.1	42.9
Others	7.2	54.1	45.9
Residence				3.2	0.077
Urban	84.4	61.7	38.3
Rural	15.6	70.1	29.9
Comorbidity				1.0	0.325
None	47.2	60.5	39.5
At least one	52.8	64.6	35.4
Regular Provider
No	41.5	68.2	31.8	4.1	0.044
Yes	58.5	59.0	41.0
Body Mass Index (BMI)
Non-obese (BMI < 30)	65.6	64.5	33.5	4.8	0.029
Obese (BMI > = 30)	34.4	56.3	43.7

Social Media Use by Smoking Status

Of the full sample (both smokers and non-smokers), approximately 71.1% of the participants reported general use of social media, while 14.4% endorsed sharing health information on social networking sites, 7.7% endorsed using online support groups, and 35.9% endorsed watching health-related YouTube videos (Table 3). Among smokers, about 13.2% endorsed sharing health information on social networking sites, 6.1% endorsed using online support groups, and 31.3% endorsed watching health-related YouTube videos. General social media usage did not differ by smoking status, as smokers were as likely as nonsmokers to report general social media use (AOR 1.12; 95% C.I 0.89 – 1.40; p = 0.338). Similar findings were observed when comparing health-related social media usage by smoking status. Specifically, in adjusted logistic regression analysis (Table 3), sharing health information on social networking sites (AOR 0.84, 95% CI 0.64 – 1.11; p = 0.224), using online support groups (AOR 0.90, 95% CI 0.64 – 1.27; p = 0.546), and watching health-related YouTube videos (AOR 0.83, 95% CI 0.66 – 1.04; p = 0.106), did not differ by smoking status.

Table 3:

Odds of Social Media Use by Smoking Status (N = 15,423)

Social Media Variable	All, N =15,423; weighted %	Non-Smokers, N = 13,560; weighted %	Smokers, N = 1,863; weighted %	Unadjusted Odds Ratio, 95% C.I.	p-value	Adjusted Odds Ratio, 95% C.I.	p-value
Visit social network site	71.1	71.4	69.4	0.91 (0.75, 1.10)	0.324	1.12 (0.89, 1.40)	0.338
Share health information on social network sites	14.4	14.6	13.2	0.89 (0.71, 1.13)	0.335	0.84 (0.64, 1.11)	0.224
Online support group	7.6	7.9	6.1	0.77 (0.56, 1.05)	0.097	0.90 (0.64, 1.27)	0.546
Watch health-related YouTube videos	35.9	36.6	31.3	0.79 (0.65, 0.95)	0.014	0.83 (0.66, 1.04)	0.106

Analysis was adjusted for age, gender, race, educational level, household income, body mass index, having a regular provider, presence of comorbidities, and rural-urban residence.

Association between Social Media Use and Health Behaviors

Table 4 shows the results of multivariable logistic regression for the association between health-related social media use with positive lifestyle behaviors among smokers. In the adjusted logistic regression, smokers who used at least one form of social media for health-related purposes in the past 12 months were significantly more likely to meet the guideline recommendation for: 1) weekly physical activity (AOR 2.00, 95% CI 1.23 – 3.24; p = 0.005), 2) daily vegetable intake (AOR 2.48, 95% CI 1.10–5.59; p = 0.029), and 3) weekly strength training (AOR 1.80, 95% CI 1.10 – 2.94; p = 0.020).

Table 4:

Multivariable Logistic Regression of Association between Health-related Social Media Utilization with Lifestyle Behaviors among Smokers (N = 1,863)

Outcomes	Unadjusted OR (95% C.I.)	p-value	Adjusted OR (95% C.I.)	p-value
Intention to quit smoking ***
Social media non-users (Reference)	1.00	----	1.00	----
Social media users	1.65 (0.94, 2.88)	0.080	1.81 (0.98, 3.34)	0.059
Attempts to quit smoking ***
Social media non-users (Reference)	1.00	----	1.00	----
Social media users	2.05 (1.21, 3.46)	0.008	1.68 (0.90, 3.12)	0.100
Daily fruit intake (>2 cups) ***
Social media non-users (Reference)	1.00	----	1.00	----
Social media users	0.64 (0.26, 1.59)	0.332	0.53 (0.17, 1.68)	0.276
Daily vegetable intake (> 2 cups) ***
Social media non-users (Reference)	1.00	----	1.00	----
Social media users	2.09 (1.05, 4.16)	0.037	2.48 (1.10, 5.59)	0.029
Weekly physical activity (> 150 mins)
Social media non-users (Reference)	1.00	----	1.00	----
Social media users	2.17 (1.47, 3.20)	<0.001	2.00 (1.23, 3.24)	0.005
Weekly strength training (>2 days/week)
Social media non-users (Reference)	1.00	----
Social media users	2.02 (1.35, 3.02)	0.001	1.80 (1.10, 2.94)	0.020

^***:participant data was only available for 2017 and 2019

Analysis was adjusted for age, gender, race, educational level, household income, body mass index, having a regular provider, presence of comorbidities, and rural-urban residence

However, the odds of reporting intentions to quit smoking (AOR 1.81, 95% CI 0.98 – 3.34; p = 0.059) and attempts at smoking cessation (AOR 1.68, 95% CI 0.90 – 3.12; p = 0.100) among smokers did not differ by social media use. Similarly, there was no association between health-related social media use and meeting daily recommendations for fruit consumption (AOR 0.53, 95% CI 0.17 – 1.68 p = 0.276).

Discussion

In this study, we used a large scale and nationally representative database of United States (US) adults to investigate the prevalence and use of social media, and the associations between social media use with current health behaviors and self-reported intentions/attempts to quit smoking in smokers. Findings indicate that although general social media use among smokers was substantial, use for health-related purposes has not been utilized to the same extent. Furthermore, we observed a positive association between health-related social media use with some health behaviors (i.e., diet, physical activity, strength training); however, associations between health-related social media use and smoking cessation outcomes were lacking.

Overall, our findings suggest that smokers in the United States have comparable access to and engagement with social media (69.4%) compared to the non-smoking population, which is consistent with data from the PEWS national research center showing that roughly 7 out of 10 Americans use any form of social media (21). Yet, despite its potentially wide reach, our findings signal that integrating these social media platforms to augment beneficial health behaviors among smokers remains relatively low. Specifically, only 13.2%, 6.1%, and 31.3% of smokers reported using social media tools to share health information, participate in an online support group, and watch health-related videos on YouTube, respectively. These results indicate an untapped opportunity for public health agencies and clinicians to deploy social media communication platforms to support and modify the health behaviors of smokers. Given the low cost, large reach, and scalability of social media platforms, our findings emphasize the need for future research focused on encouraging health-related social media usage for smokers.

Social media offers a promising opportunity to foster positive health behaviors and may contribute to the improvement of quality of life and mortality in smokers. Consistent with previous studies (Goodyear et al., 2021; Shimoga et al., 2019), we observed that after controlling for sociodemographic and health-related factors, smokers who endorsed health-related social media use were more likely to achieve nationally recommended guidelines for diet and weekly levels of physical activity and strength training than those who did not. These results provide real-world evidence supporting the notion that social media may be used to offer behavioral interventions to smokers and suggests a clinically relevant opportunity to further utilize social media to reduce the elevated mortality among smokers.

In contrast, we found no association between health-related social media use and attempts to quit smoking. So far, research on the role of social media in promoting smoking cessation has yielded mixed findings. While a favorable association between social media use and smoking cessation outcomes (40) is known, our findings are consistent with inconclusive results regarding the effectiveness of social media for smoking cessation. For example, a systematic review of 12 studies by Thrul and colleagues found that social media interventions for smoking cessation yield mixed results, with some studies reporting significant reductions in smoking rates and others reporting no effect (32). Similarly, a randomized controlled trial of a Facebook smoking cessation intervention found no significant difference in quit rates between the intervention and control groups at the end of one year (41). Thus, our results extend the debate regarding the real-world effectiveness of social media platforms in promoting tobacco cessation. Further research is needed to demonstrate the effectiveness of social media tools for smoking cessation in real-world settings.

Although there is limited evidence regarding the efficacy and effectiveness of social media in stimulating smoking behavioral change, social media has the potential to address several unmet needs of smokers and are viable platforms to promote smoking cessation content. For example, social media can provide access to health information and resources that may not be readily available through traditional healthcare channels like yearly physicals and patient medical portals. Similarly, social media may provide a means for peer and social support by encouraging smokers to interact with others who are also trying to quit smoking and to share experiences and strategies for behavior change. Additionally, given their low cost and widespread availability, social media platforms offer unique opportunities to overcome financial and geographic barriers to quitting smoking. Although research on the role of social media in improving the health of smokers continues to emerge, our work extends already existing literature (42) and identifies specific areas of current success, such as diet and physical activity, while emphasizing others for further research such as smoking cessation.

Despite their benefits, social media platforms are not without challenges. The ability to freely share videos, texts, and graphic images to a large audience via social media has afforded an opportunity for targeted marketing by tobacco companies. Evidence suggests that exposure to smoking content on social media appears to be an important avenue for subsequent tobacco initiation among youth and young adults (43, 44). Similarly, social media may amplify and perpetuate the propagation of tobacco-related misinformation, especially among vulnerable groups (45). For example, in a study evaluating the feasibility of a Facebook smoking cessation intervention among young adults, authors found that electronic cigarettes were used more frequently as a cessation aid than nicotine replacement therapy, even though their use was not recommended in the intervention. Another study examined the effects of misleading content related to smoking on YouTube among 350 young adults. This study observed that those who viewed misleading information about e-cigarettes and hookahs reported more favorable attitudes toward these products than the control group (46). As the social media landscape continues to rapidly evolve, policymakers and public health agencies should focus on enacting regulatory policies to limit social media tobacco marketing and conduct surveillance on tobacco-related information on social media. Relatedly, public health organizations can consider social media as a medium to disseminate information related to smoking cessation, positive lifestyle behaviors, and the health benefits of cessation.

Strengths and Limitations

A major strength of this study is that it is among the first studies to use a large, nationally representative, and diverse sample of US adult smokers to explore the potential impact of social media usage on health behaviors and smoking cessation outcomes. Thus, our data offer useful insights and extend the literature on social media for health promotion in smoking populations. Second, our employment of sampling weights enables us to generalize our findings to the entire US population. Also, our results are based on the most recent data using the 2017 to 2020 iterations of HINTS.

Notwithstanding these strengths, some limitations are worth highlighting. First, HINTS provides a cross-sectional database which makes it difficult to make causal inferences (47). This cross-sectional design does not allow us to discern whether health-related social media use directly influences health behaviors or whether individuals with specific health behaviors are more inclined to pro-actively engage with health-related content on social media. Second, the self-reported nature of the data limits our ability to characterize the type, duration, engagement levels, content, and frequency of social media use (48). The survey questions pertaining to social media engagement did not capture the full spectrum of user activity. For instance, while our data assessed ‘participation’ in online forums, it did not differentiate between various levels of engagement such as passive activities like viewing, and active activities like reading, liking, or commenting. Relatedly, information on health-related usage was limited, and it was not possible to determine if usage was specific to smoking cessation or other non-smoking-related purposes. Third, although self-reported smoking cessation outcomes have been reported in past survey-based studies (49), there remains the potential for recall or misrepresentation bias. Lastly, the response rate for all iterations of HINTS from the 2017 to 2020 data used ranged from 32.4% to 36.7%, suggesting the potential for non-response bias (50).

Future research should consider longitudinal approaches, utilize objective outcome measures (smoking, physical activity, diet), and examine aspects of social media (type, characteristics, content, engagement levels, and frequency of use) that are most critical in stimulating health behavior change among smokers.

Conclusion

These findings extend the literature on the role of social media in improving health outcomes among smokers. Although general social media use among smokers was substantial, the use of social media for health-related purposes has not increased to the same extent. Findings also suggest that while social media use can potentially reach a large audience and may support some positive lifestyle behaviors, usage of social media alone may not directly influence smoking behavior changes.