Framing Effects in Youth E-Cigarette Use Prevention: Individual Text Messages Versus Simulated Text Exchanges

Abstract

Electronic cigarettes are the most widely used tobacco product among youth in the United States. Although rapidly growing, research on effective message strategies for e-cigarette use prevention is still limited. This study examined the relative effectiveness of gain framing versus loss framing in youth-targeting prevention text messages delivered either as individual expository texts or simulated text exchanges between a youth patient and a pediatrician. A national sample of 1,084 youth susceptible to future e-cigarette use was randomized to condition in an online message testing experiment featuring a 2 (framing: gain vs. loss) × 2 (format: individual texts vs. simulated exchange) factorial design. Results revealed a consistent interaction between framing and messaging format in message liking, positive affect, attitude toward e-cigarette use, and future e-cigarette use intentions. The gain frame outperformed the loss frame in the simulated exchange conditions while the reverse trend was true for the individual text conditions. Furthermore, the main effect of messaging format was significant on multiple outcomes in favor of simulated text exchanges. The main effect of framing was only significant on negative affective response with the loss frame eliciting stronger responses. These findings suggest that the relative effectiveness of gain framing versus loss framing depends on how messages are presented in youth-targeting text messaging interventions. When messages are likely to be delivered in a discrete manner, the loss frame should be preferred. When greater interactivity and narrative development are possible, the gain frame should be favored. E-cigarette prevention efforts should leverage these insights to enhance message effectiveness.

Electronic cigarettes, or e-cigarettes, are the most widely used tobacco product among youth in the United States (Gentzke et al., 2022). In 2021, 11.3% of high school students and 2.8% of middle school students reported e-cigarette use in the past 30 days (Park-Lee et al., 2021). In response to this concerning trend, government agencies and public health organizations have mounted prevention campaigns to educate young people on the harms of e-cigarette use. National examples include the Food and Drug Administration’s The Real Cost campaign (Zeller, 2019) and the Truth Initiative’s truth campaign (Hair et al., 2023).

Successful e-cigarette use prevention campaigns require both persuasive messages and effective strategies to engage the youth population. Although rapidly growing, the literature on e-cigarette use prevention messaging is still relatively limited. Extant research has focused most intensively on the relative effectiveness of different content themes, such as toxic chemicals, addiction, and mental health (Roditis et al., 2020; Rohde et al., 2020). There is also research on structural features that are suited for specific platforms of messaging, such as textual and/or iconic warnings and social media posting (Brewer et al., 2019; Lazard, 2021; Mays et al., 2019). Building upon previous work, this study examines another potentially useful message strategy in youth e-cigarette use prevention: gain framing versus loss framing.

Most health messages can be framed in terms of either gains or losses (Meyerowitz & Chaiken, 1987; Rothman & Salovey, 1997). Simply put, gain framing focuses on the benefits of compliance with a health recommendation, while loss framing focuses on the costs of noncompliance. An important feature of framing is that it is a relatively straightforward message manipulation, particularly in textual or print messages. This makes it an attractive message strategy to consider for health interventions. The framing literature is vast and complex. The current evidence base suggests that the effects of gain framing versus loss framing are best examined within specific behavioral contexts; sweeping conclusions about the superiority of one frame over the other across diverse health behaviors have proven elusive (O’Keefe & Jensen, 2007, 2009).

Specific to tobacco, existing studies on gain framing versus loss framing have focused more on smoking cessation messages targeting adults than prevention messages targeting youth. Results from these studies are somewhat mixed—one meta-analysis showed an advantage for the gain frame among smoking cessation messages (Gallagher & Updegraff, 2012) while another showed no difference between the two frames when cessation and prevention messages were jointly considered (O’Keefe & Jensen, 2007). The youth smoking prevention literature has generally supported the effectiveness of message strategies in line with loss framing (e.g., negative emotional appeals) (Allen et al., 2015; Farrelly et al., 2003). Framing research in the context of e-cigarette use prevention is limited. An early study showed a preference for the loss frame among youth and young adults for messages on health risks and addiction (Kong et al., 2016). This preference was confirmed by recent data from our team which found loss-framed text messages to hold an overall advantage over gain-framed text messages, although this advantage was further moderated by individual tolerance of uncertainty such that the loss frame was particularly effective with those high in uncertainty tolerance while the gain frame held a slight edge among those low in uncertainty tolerance (Cai & Zhao, 2021).

The current study builds on this previous analysis and considers the interplay between framing and format of message delivery. Text messaging is a promising intervention strategy for the youth population because of the ubiquitous presence of mobile phones among youth today (Pew Research Center, 2018). A recent pilot study showed that youth were generally receptive to e-cigarette harms messages through text messaging (Noar et al., 2019). Given the interactive potential of text messaging, we are interested in the possibility that the effect of gain framing versus loss framing might pan out differently when the same messages are presented either as individual texts or as simulated message exchanges.

In some ways, individual text messages can be viewed as discrete persuasive arguments, each addressing a particular reason why e-cigarette use is unwise. Simulated text message exchanges integrate these individual arguments into a coherent dialogue between fictional characters. As such, they take on the properties of an evolving narrative, albeit in a rudimentary and restricted form (Kreuter et al., 2007). To be sure, text message exchanges often lack the space and ability to develop elaborate story lines, but they are also not simple compilations of discrete informational messages. By integrating receiver reactions and perspectives (even if on a limited basis), these exchanges can capture and reflect basic interpersonal dynamics and develop the texture of a story or narrative. Compared with expository or didactic messages, narratives are believed to have important advantages in audience engagement, ease of processing, and overcoming resistance (Kreuter et al., 2007; Slater & Rouner, 2002). Meta-analyses show that narratives are generally more effective at inducing message-consistent changes in beliefs, attitudes, intentions, and behaviors than non-narratives (Braddock & Dillard, 2016; Shen et al., 2015).

As narratives demand less cognitive efforts, the gain frame may work particularly well with this messaging format. Previous research suggests that, while the loss frame requires deep processing, the gain frame performs well with limited processing (Block & Keller, 1995; Meyers-Levy & Maheswaran, 2004). A few studies have examined the interplay between framing and narrative persuasion in the tobacco context, without showing a consistent pattern (Kim & Lee, 2017; Ma & Nan, 2019). One recent study specifically looked at framing and narratives for vaping prevention among college students (Liu & Yang, 2020). It showed that transportation and discrete emotions were responsible for a complex, and sometimes countervailing, pattern of framing effects on behavioral intention. To the best of our knowledge, no prior research has examined the interaction between framing and narrative persuasion in the context of youth-targeting e-cigarette use prevention messaging.

This study aims to fill this void. Based on previous findings, we expect the loss frame to hold an overall advantage in message receptivity and persuasive outcomes. We also expect simulated text message exchanges to be better received than simple presentation of individual text messages. Given the limited prior evidence, the potential interaction between framing and narratives is treated as an open research question in this study.

Method

Youth at risk of e-cigarette use participated in an online message testing experiment featuring a 2 (framing: gain vs. loss) × 2 (format: individual texts vs. simulated exchange) factorial design. Participants were recruited through Qualtrics using its online sample aggregation service. Email invitations were sent to adult panel members with age-eligible children, informing them of the opportunity to participate. Those interested in having their children participate were then sent a link to the study. Both parental consent and youth assent were obtained before data collection. In all study materials, we referred to e-cigarette use as vaping to be consistent with popular youth terminology. The study protocol and materials were approved by the authors’ home institution’s institutional review board (IRB).

As acknowledged earlier, we reported some of the data in a previous publication, focusing on the two individual text conditions (Cai & Zhao, 2021). This previous analysis did not include the simulated exchange conditions because a key moderator of interest, individual uncertainty tolerance, was not measured in these conditions by design. We were interested in several psychological trait variables that were each measured with a lengthy scale. Due to survey space limit, we randomly assigned these measures to only half of the conditions. The current analysis does not involve these variables and uses data from all four conditions to address questions related to framing, messaging format, and their potential interaction.

Sample

Qualification criteria for this study included 13 to 17 years in age, no participation in any tobacco-related research in the past 6 months, and susceptibility to future e-cigarette use (see measurement detail below). Soft quotas were set during recruitment to ensure roughly equal numbers of male and female participants and a relatively even split in age between 13–15 and 16–17. A total of 5,976 youth were screened and 1,084 (18.1%) qualified and completed the full experiment. Participants were rewarded through Qualtrics’s internal incentive system.

Messages

Messages for the study were developed through multiple steps. First, we conducted a careful literature review to identify important content themes that focus on the harms of e-cigarette use (Lazard, 2021; Roditis et al., 2019, 2020; Sangalang et al., 2019; U.S. Department of Health and Human Services [DHHS], 2016). A summary document of key health consequences, sample messages, and salient beliefs tested in previous research was created. Based on this summary, 15 preliminary messages were developed by the research team and went through rounds of review and revision. Each message was rendered in two alternative frames, one highlighting the negative consequences of e-cigarette use (loss frame), and the other the avoidance of such consequences by not using e-cigarettes (gain frame). Second, we conducted in-depth interviews with a locally recruited convenience sample of 20 adolescents aged 13 to 17. Participants were asked, among other things, whether each message/theme resonated with them, whether they were able to identify the frame of the message, and what improvements they would recommend. The interviews were transcribed verbatim and members of the research team independently read the transcripts multiple times and identified themes in participant reactions. The team then compared notes, consolidated similar themes, and discussed and resolved disagreements. Based on interview findings, the messages were further revised, some removed, and a subset of eight messages (in both frames) were retained for use in the current study. The content of the messages covered four general themes: harms of nicotine, dangerous chemicals, mental health, and injury from device explosion.

After finalizing the individual, expository messages, we developed two simulated text message exchanges between a youth patient (Jamie) and their pediatrician (Dr. Kaufman). One script consistently used the gain frame, the other the loss frame. The individual messages were woven into the exchanges with slight modifications to ensure a natural flow of the conversation. All messages used in this study can be found in Supplemental Materials.

Procedure

Data collection occurred in November and December 2020. The study began with a brief screener to determine eligibility. Eligible participants completed a baseline questionnaire before being randomized to condition. In the individual text conditions, participants were instructed to imagine that they were receiving the messages, one per day, from their own pediatrician or family doctor. In the simulated exchange conditions, participants were told that they would be seeing records of text message exchanges between a youth patient and their pediatrician. In the individual text conditions, each message was presented as a separate smartphone screenshot and stayed on for a minimum of 4 s before participants could move forward. In the simulated exchange conditions, the messages were presented in eight sequential screenshots that captured the entire conversation. Each screenshot stayed on for a minimum of 10 s. After viewing all the messages appropriate to condition, participants completed post-test measures of interest.

Measures

In the screener, participants were first asked whether they had ever vaped (yes/no) and if yes, if they had vaped during the past 30 days (yes/no). Regardless of e-cigarette use status, they were also asked about susceptibility to future e-cigarette use using an adapted form of the smoking susceptibility scale (Pierce et al., 1996). While the susceptibility measure is commonly used with never users, it can also be used with other groups because it consists of questions about intentions for future behavior. Previous research has asked this measure of ever and current smokers to determine participants’ openness to future tobacco use (Feighery et al., 1998; Pierce et al., 1995). Three questions assessed likelihood of using an e-cigarette “soon,” “in the next year,” and “if one of your best friends were to offer you a vape,” with responses of “definitely yes,” “probably yes,” “probably not,” and “definitely not.” Any participant who did not respond “definitely not” to all three questions was deemed susceptible and qualified for the study. To capture variation in susceptibility, an overall score of susceptibility was calculated by averaging the three items after reverse coding.

The baseline questionnaire included five semantic differential items on attitude toward e-cigarette use, even once or twice, within the next 12 months. Anchors included “good/bad,” “wise/foolish,” “safe/dangerous,” “pleasant/unpleasant,” and “enjoyable/unenjoyable” (Fishbein et al., 2001). Responses were indicated on a 5-point scale and averaged into a summary score after reverse coding where a higher score represented greater favorability toward e-cigarette use. Demographic measures included sex, age, and race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other).

After exposure, participants completed a number of measures assessing their liking and evaluation of the messages, their emotional experience during message exposure, their perceptions about the outcomes of e-cigarette use, and their attitude (i.e., general evaluative judgment) and intentions regarding e-cigarette use. These measures are commonly used in persuasion and health communication studies to capture audience reactions and message effects (National Cancer Institute, 2002; O’Keefe, 2016). Participants first reported the extent to which they liked the messages they saw (1 = strongly dislike to 7 = strongly like). They then rated perceived message effectiveness using a 10-item instrument drawing from several published scales (Baig et al., 2019; Davis et al., 2013; Zhao et al., 2011). Items evaluated the extent to which the messages were “believable,” “convincing,” “informative,” “said something important to me,” “gave me good reasons for not vaping,” “grabbed my attention,” “told me things I never knew before about vaping,” “discourage me from wanting to vape,” “make vaping seem unpleasant to me,” and “make me concerned about the health effects of vaping.” Responses were indicated on a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree) and averaged across the 10 items. A higher summary score represented greater perceived effectiveness. Emotions experienced during exposure to the messages were captured with worried, afraid, uneasy for negative and hopeful, determined, inspired for positive affective responses (Crawford & Henry, 2004). Each item was rated from 1 “not at all” to 5 “a great deal.” Summary scores of negative and positive affective responses were created by averaging across the appropriate items, and higher summary scores indicated stronger responses.

Beliefs about the consequences of e-cigarette use were assessed using 16 items culled from relevant literature (Gibson et al., 2018; Roditis et al., 2020; Sangalang et al., 2019). All belief statements followed the stem “If I vape, I will . . .” The negative beliefs (k = 13) included items such as “be controlled by vaping,” “harm my brain,” and “inhale toxic chemicals” and largely corresponded with the themes covered by the text messages. The positive beliefs (k = 3) included “look cool,” “look more mature,” and “fit in with groups I like.” Responses were indicated on a 5-point Likert-type scale and averaged into two summary scores for negative and positive beliefs, respectively. Higher summary scores represented stronger beliefs.

Attitude toward e-cigarette use was measured again in the post-test questionnaire using the same items as in the baseline survey. Intentions were assessed by asking how likely participants would vape “even if just once,” “occasionally,” and “on a regular basis,” in the next 12 months. These items were designed to capture intentions for trial, occasional, and regular use, respectively, a classification often recognized in tobacco research (Mowery et al., 2004). Responses ranged from 1 “extremely unlikely” to 5 “extremely likely” and were highly correlated across the three items (r = .84–.90). The three items were averaged into an overall measure of e-cigarette use intentions, with higher scores indicating stronger intentions.

Qualtrics’ quality control ensured minimal missing data in the final data set (<1%). The construction of summary scores used all items with non-missing data for each participant. For example, if a participant had a missing value for one item on the 10-item perceived message effectiveness scale, a summary score would be constructed for them using the remaining nine items with non-missing data.

Analysis

We conducted descriptive analyses to capture sample characteristics. Chi-square tests and analyses of variance (ANOVAs) were used to evaluate equivalence between study conditions on baseline measures. The main analyses were a series of two-way (framing × format) analyses of covariance (ANCOVAs) on post-exposure outcome measures adjusting for baseline susceptibility and attitude as well as any difference detected in equivalence checks. As attitude was measured both before and after message exposure, a paired-sample t-test was conducted to assess pre-post change in attitude. Preliminary analysis assessed potential differences between ever/current and never users in the sample but did not see clear differentiation between these groups, likely due to the use of susceptibility as an inclusion criterion in the study. The final analysis was thus conducted with the full sample without stratification by use status. All analyses were performed using SPSS v.28.

Results

Sample characteristics are summarized in Table 1. Reflecting the high-risk profile of the sample, the majority of the youth participants had used e-cigarettes in the past 30 days. Their baseline susceptibility was relatively high and attitude toward e-cigarette use was above scale mid-point. The conditions were largely equivalent at baseline on most demographics, e-cigarette use experience, and baseline susceptibility and attitude (see Table 1). The only significant difference observed was with age across the framing conditions (p = .04). Age was thus included as a covariate in all tests of condition differences in study outcomes.

Table 1.

Sample Characteristics (N = 1,084).

	Full sample	Gain (n = 539)	Loss (n = 545)		Individual texts (n = 537)	Text exchanges (n = 547)
Charateristics	%	%	%	p	%	%	p
Male	51.8	51.2	52.8	.611	52.0	53.8	.239
Female	47.9	48.8	47.2		49.8	46.2
Nonbinary or other	0.3
13	14.9	14.7	15.0	.04	14.9	14.8	.456
14	14.9	11.9	18.0		16.9	13.0
15	22.0	21.7	22.2		21.8	22.1
16	22.2	24.5	20.0		21.4	23.0
17	26.0	27.3	24.8		25.0	27.1
Non-Hispanic White	78.1	78.8	77.4	.572	76.4	79.9	.159
Non-Hispanic Black	6.7	5.4	8.1	.077	7.8	5.7	.157
Hispanic	14.2	14.1	14.3	.920	14.2	14.3	.960
Other race/ethnicity	3.0	3.2	2.9	.834	3.9	2.2	.100
Ever vaping	76.0	76.1	76.0	.968	77.5	74.6	.267
Past 30-day vaping	60.1	61.6	58.7	.333	59.8	60.5	.805
	M (SD)	M (SD)	M (SD)		M (SD)	M (SD)
Susceptibility to future vaping (α = .92)	2.97 (0.88)	3.02 (0.87)	2.94 (0.89)	.147	2.96 (0.88)	3.0 (0.88)	.483
Baseline attitude toward vaping (α = .93)	3.28 (1.28)	3.31 (1.29)	3.24 (1.27)	.362	3.29 (1.25)	3.27 (1.25)	.778

Main effects from the two-way ANCOVAs are summarized in Table 2. The main effect of framing emerged significant on only one outcome. The loss frame generated stronger negative affective responses than the gain frame (p < .001). The main effect of messaging format was significant for several outcomes. Compared with individual text messages, the simulated text exchanges were better liked (p < .001), rated higher on perceived message effectiveness (p < .001), elicited greater positive affect (p < .001), increased beliefs about the negative consequences of e-cigarette use (p < .001), and produced more negative attitudes toward e-cigarette use (p = .028).

Table 2.

Condition Differences on Message Receptivity, Vaping-Related Beliefs, Attitude, and Intentions.

Outcome variable	Gain M (SE)	Loss M (SE)	p/eta2	Individual texts M (SE)	Text exchanges M (SE)	p/eta2
Liking	4.35 (0.04)	4.31 (0.04)	.465/.000	4.16 (0.04)	4.49 (0.04)	<.001/.036
Negative affect (α = .83)	2.83 (0.05)	3.11 (0.05)	<.001/.015	2.93 (0.05)	3.00 (0.05)	.293/.001
Positive affect (α = .90)	3.58 (0.05)	3.58 (0.05)	998/.000	3.41 (0.05)	3.75 (0.05)	<.001/.020
Perceived message effectiveness (α = .91)	4.27 (0.03)	4.32 (0.03)	.288/.001	4.20 (0.03)	4.38 (0.03)	<.001/.014
Negative consequences (α = .94)	4.09 (0.04)	4.06 (0.04)	.559/.000	3.96 (0.04)	4.18 (0.04)	<.001/.017
Positive consequences (α = .85)	2.80 (0.05)	2.67 (0.05)	.052/.004	2.76 (0.05)	2.71 (0.05)	.496/.000
Attitude (α = .95)	2.31 (0.05)	2.37 (0.05)	.440/.001	2.42 (0.05)	2.27 (0.05)	.028/.004
Intentions (α = .95)	2.39 (0.05)	2.32 (0.05)	.389/.001	2.37 (0.05)	2.34 (0.05)	.704/.000

Note. Results obtained from ANCOVAs adjusting for age, susceptibility, and attitude toward vaping at baseline. ANCOVA = analysis of covariance. Bolded differences are significant at p < .05.

Notably, the interaction between framing and messaging format was significant for multiple outcomes. As shown in Figure 1, the pattern of the interaction was consistent on message liking (p = .011), positive affect (p = .030), attitude toward e-cigarettes (p = .026), and intentions to use e-cigarettes (p = .025). The loss frame produced more favorable results for individual text messages while the gain frame worked better for the simulated text exchanges.

Figure 1.

Interaction Between Framing and Message Format.

Note. Covariates included age, susceptibility, and attitude toward vaping at baseline. Error bars are 95% confidence interval.

A significant pre-post change in attitude toward e-cigarette use was observed for the full sample (p < .001, d = .732). Compared with baseline (M = 3.28, SD = 1.28), post-exposure attitude was significantly more negative (M = 2.34, SD = 1.35). Further exploration did not show this pre-post change to vary significantly across message conditions.

Discussion

This study investigated the relative effectiveness of gain framing versus loss framing in e-cigarette use prevention text messaging targeting youth susceptible to future e-cigarette use. The same educational content was presented in two different formats, either as individual expository messages or as a simulated text message exchange between a pediatrician and a youth patient. The most interesting finding from the study was a consistent pattern of interaction between framing and messaging format. The gain frame was better liked, elicited stronger positive affect, and generated less favorable attitudes and lower intentions toward e-cigarette use than the loss frame for the simulated text exchange; the opposite trend was observed with the individual expository text messages. In addition, regardless of framing, participants reacted to the simulated text exchanges more favorably than the individual expository messages. They rated the simulated exchanges higher on liking, positive affect, and perceived message effectiveness. Participants also indicated greater agreement with the negative consequences of e-cigarette use and exhibited more negative attitudes toward e-cigarettes post exposure to the simulated exchanges. By contrast, framing only produced one significant main effect in the current analysis—the loss frame produced stronger negative affect than the gain frame when data were collapsed across the two modes of presentation.

Previous research on youth tobacco prevention has generally supported the effectiveness of message strategies in line with loss framing (Allen et al., 2015; Farrelly et al., 2003). The observed effects with expository messages in the current analysis were largely consistent with these previous findings. However, when the same message content was integrated into a simulated text exchange, the advantage of the loss frame disappeared. Instead, we observed fairly consistent superiority of the gain frame not only in cognitive and affective responses to the messages but also in e-cigarette attitudes and intentions.

We suspect that this reversal of framing effect had to do with the narrative qualities of the simulated text exchanges. By weaving educational messages into an evolving conversation between a health care provider and a youth patient, a different experience was introduced for the participants. They were no longer exposed to isolated didactic messages, but a simple “story” that featured two characters and a health-related story line. Granted, text message exchanges are a limited form of narrative, lacking both space and details to fully tap into the powers of story-telling. But even this rudimentary form of narrative seemed to be enough to change how youth audience processed the incoming information. Research on narrative persuasion suggests that narratives can decrease analytical processing and encourage experiential learning (Green & Brock, 2000; Kreuter et al., 2007). The framing literature, at the same time, shows that the loss frame tends to be more effective with deep, systematic processing, while the gain frame can be more persuasive with less effortful and more heuristic-based processing (Block & Keller, 1995; Meyers-Levy & Maheswaran, 2004). To the extent that the narrative nature of the simulated text exchanges was conducive to heuristic processing, the advantages of the gain frame observed in this study are in line with these previous findings.

Also consistent with previous research on narrative persuasion (Braddock & Dillard, 2016; Shen et al., 2015), we observed stronger performance of the simulated text exchanges relative to expository messages, regardless of framing. While narrative messages are often complex, this study shows that even relatively simple narratives based on text messaging can improve intervention outcomes compared with discrete didactic texts. Youth-targeting text messaging-based e-cigarette cessation programs already exist (Graham et al., 2020). Continued investigation into narrative text messaging strategies will benefit the growth of these programs.

Findings of this study have important implications for youth e-cigarette use prevention. First, the relative strengths of gain framing versus loss framing should be considered in prevention message development. The current data show that, under the right condition, either gain or loss framing may bring about important improvements in intervention outcomes. Second, text messages are an important tool for youth e-cigarette use prevention. In addition to benefits already documented in the literature (Spohr et al., 2015), their pliability to strategic manipulation, such as framing, is another advantage to consider in program development. Third, to the extent possible, it is important to engage health care providers in interactions with the target audience in text messaging interventions. The kind of exchanges featured in the current study is entirely feasible in interactive messaging environments such as patient portals (Han et al., 2019; Irizarry et al., 2015). Indeed, messaging and information procurement are some of the most important functions of patient portals as identified by their users (Griffin et al., 2016; Perzynski et al., 2017). The overall advantage of simulated exchanges over discrete texts as seen in this study points to the benefit of interactive messaging. However, framing effects in patients’ personal interactions with providers might differ from those in reading other people’s exchanges. Further research is needed to evaluate this possibility. Fourth, the effectiveness of simulated text exchanges observed in this study suggests that at-risk youth may benefit from vicarious learning from other youth’s experiences in seeking consultation with their health care providers. Indeed, from a social learning perspective (Bandura, 1998), the gain frame might have worked better with the simulated exchanges because they offered more modeling opportunities of health-protective behaviors. While direct viewing of other people’s private text messages is usually not possible, opportunities to observe real or simulated exchanges in other forms of messaging, such as print advertising or online videos, may still bring important benefits. For example, campaigns may create posters, videos, or social media animatics featuring brief text message exchanges between youth and their providers around e-cigarette use. The current findings suggest that even passive exposure to such materials may bring about meaningful outcomes.

The limitations of the study should be acknowledged. First, the study is a one-time experiment with no behavioral follow-up. It is unclear how well the effects observed in this study might translate into actual behavior change. Second, this study lacks a no-message control condition. The observed message effects are thus relative in nature, not absolute. Third, although our study stimuli were educational text messages, we did not test them in the environment of an actual text messaging intervention. Future research should look to replicate and extend the current findings in real-world applications. Fourth, we suspect that the interaction between framing and messaging format might have to do with different styles of information processing. We did not have measures in this study to directly test this possibility. This could be an interesting direction for future research. Finally, this study observed important advantages of simulated text exchanges. This messaging format is necessarily more complex than individual text messages. Although this is a common issue in narrative research, it is nonetheless important to acknowledge that factors external to framing might have also contributed to the observed effects.

Conclusion

This study has contributed useful evidence to the literature on message design in youth e-cigarette use prevention. It shows that the relative effectiveness of gain framing versus loss framing may depend on how message presentation is structured in an intervention. E-cigarette use prevention efforts should leverage these insights to enhance the effectiveness of their messaging.

Supplementary Material

Supplemental material for this article is available online at https://journals.sagepub.com/home/heb.