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Published in final edited form as: Addict Behav. 2017 Nov 10;78:120–123. doi: 10.1016/j.addbeh.2017.11.012

Exposure to tobacco websites: Associations with cigarette and e-cigarette use and susceptibility among adolescents

Jennifer B Unger 1, Lauren Bartsch 2
PMCID: PMC5783751  NIHMSID: NIHMS921654  PMID: 29154150

Abstract

Introduction

Exposure to tobacco advertising is a risk factor for tobacco use and susceptibility among adolescents. Although tobacco company websites are ostensibly targeted to adults, some youth access these websites and are exposed to tobacco-related content.

Methods

This study analyzed data from the Population Assessment of Tobacco and Health (PATH) survey to estimate the prevalence of exposure to tobacco websites and the associations between website exposure and tobacco product use and susceptibility among adolescents in the United States.

Results

Although only 2.3% of youth had ever visited a tobacco company website, youth who visited tobacco company websites were 3.2 times more likely to have used cigarettes and 3.0 times more likely to have used e-cigarettes in the past month, relative to those who had not visited a tobacco website. Among never-users, those who had visited tobacco company websites were 2.4 times more likely to be susceptible to cigarettes and 2.9 times more likely to be susceptible to e-cigarettes.

Conclusions

Results indicate that more effective regulations are needed to prevent youth from accessing tobacco websites. Stricter age verification procedures on websites could minimize exposure to tobacco websites by youth.

Keywords: Tobacco, cigarettes, e-cigarettes, internet, websites, advertising, adolescents

Introduction

In 2016, 20.2% of United States (US) high school students and 7.2% of middle school students reported using nicotine or tobacco products in the past month (Jamal et al., 2017). Electronic cigarettes (e-cigarettes) have surpassed combustible cigarettes as the most frequently used tobacco product among US adolescents; 11.3% of high school youth and 4.3% of middle school youth reported past-month e-cigarette use in 2016, compared to only 8.0% of high school students and 2.2% of middle school students reporting past-month cigarette use (Jamal et al., 2017).

Preventing tobacco use among youth is an important public health priority as 90% of adult cigarette smokers started before age 18, and cigarette smoking remains the leading cause of preventable mortality (CDC, 2016). Although e-cigarettes are probably less harmful than combustible cigarettes, they still expose users to nicotine (with its addictive properties and effects on the developing brain) and carcinogens, and their long-term health effects are unknown (Callahan-Lyon, 2014; FDA, 2016; Smith, Brar, Srinivasan, Enja, & Lippmann, 2016). Therefore, the safest option for adolescents is to refrain from use of any nicotine or tobacco products, and public health efforts are needed to protect adolescents from influences that might encourage them to experiment with nicotine or tobacco.

Decades of research have demonstrated associations between exposure to tobacco marketing and tobacco use among adolescents (US. Department of Health and Human Services, 2012). In addition to traditional channels such as magazines and retail advertising, youth now can view tobacco advertising on the Internet, including tobacco company websites and social media (Dai & Hao, 2016; Dube et al.,2013). Studies have documented associations between self-reported exposure to online e-cigarette marketing and e-cigarette use (Dai & Hao, 2016; Fulmer, et al, 2015; Mantey et al., 2016; Singh, et al., 2016). Despite legislation and agreements banning tobacco advertising to youth, including the 1998 Master Settlement Agreement, the 2009 Family Smoking Prevention and Tobacco Control Act, and the 2016 FDA Deeming Rule, tobacco companies are still spending nearly $9 billion dollars annually on cigarette advertising and promotion, including $16 million on company websites (FDA, 2017; Federal Trade Commission [FTC], 2016; Tobacco Free Kids, 2003). Current regulations may not adequately prevent youth from viewing tobacco advertising and purchasing tobacco online (Freeman, 2012; Williams, Derrick, & Ribisl, 2015). Although most major tobacco companies use strict age verification procedures to prevent youth access to their websites, some smaller tobacco companies and online tobacco product retailers do not (Williams et al., 2017). Some tobacco company websites merely require users to click a button or enter a birthdate to indicate that they are over age 18 or 21, without verifying this information (Escobedo in press).

The lack of regulation of online tobacco advertising and sales creates an opportunity for adolescents to access tobacco information and products. The difficulty in regulating content on the Internet, paired with the inability to determine if available pro-tobacco content is authored by tobacco companies or their affiliates, creates a major enforcement challenge (Freeman, 2012; Ribisl & Jo, 2012). Nonetheless, regulation in this medium should remain a high priority as pro-tobacco content likely encourages initiation and normalizes use (Ribisl & Jo, 2012; Sloboda, Glantz, & Tartar, 2012).

There are gaps in the literature regarding the relationship between Internet exposure to tobacco content and youth smoking (Forsyth, Kennedy, & Malone, 2013). This article examines associations between tobacco website engagement and tobacco product use and susceptibility. Specifically, we used national data to estimate the proportion of US adolescents who visit tobacco websites and to determine whether visiting tobacco websites is associated with tobacco use prevalence and susceptibility.

Methods

Data source

Data were obtained from the Population Assessment of Tobacco and Health (PATH) Wave 1 public-use dataset. PATH is a nationally-representative, longitudinal cohort study of non-institutionalized adult and youth residents of the US ages 12 and older (Hyland et al., 2016). Wave 1 data were collected from September 2013 through December 2014. The youth dataset includes self-reported data from 13,651 adolescents ages 12–17 in selected households. Sampling weights are used to adjust for the study design and nonresponse to provide population estimates (Hyland et al., 2016). Among selected youth aged 12–17, the weighted completion rate was 78.4%. All respondents provided parental consent and adolescent assent. Data collection was approved by the Westat Institutional Review Board, and data analysis was approved by the University of Southern California Institutional Review Board.

Measures

To assess website exposure, participants were shown screenshots of five tobacco brand websites in random order: Camel, Marlboro, Newport, Swisher, and Blu. These brands represented the two most popular cigarette brands, the most popular menthol cigarette brand, the most popular cigarillo brand, and the most popular e-cigarette brand at the time of the study. For each website, they were asked, “This is the website for [BRAND]. In the past 6 months, have you been to this website?” Response options were yes or no. This variable was coded as the number of websites the participant had seen (range=0–5) and was dichotomized to 0 websites vs. 1 or more websites because the distribution was skewed.

Tobacco product use was asked separately for cigarettes and e-cigarettes. Lifetime use was defined as a “yes” response to the question, “Have you ever tried [product], even one or two puffs?” Respondents who had ever tried the product were asked, “In the past 30 days, on how many days did you smoke [product]?” Participants were coded as past-month tobacco product users if they reported using the product on one or more days in the past month.

Susceptibility to tobacco product use indicates the lack of a firm commitment not to use the product; it is designed to separate committed never-users from adolescents who express interest in trying a tobacco product in the future (Trinidad et al., 2017). Adolescents reported their susceptibility to cigarettes and e-cigarettes separately. Respondents were coded as susceptible if they provided any response other than “definitely not” to any of the following questions: “Have you ever been curious about [product]?” or “Do you think you will try [product] in the next year?” or “Do you think you will try [product] soon?” or “If one of your best friends were to offer you [product], would you smoke it?”

Analysis

Logistic regression was conducted to determine whether tobacco website exposure was associated with tobacco product use and susceptibility. Separate models were run for the six outcome variables: lifetime cigarette use, lifetime e-cigarette use, past-month cigarette use, past-month e-cigarette use, cigarette susceptibility, and e-cigarette susceptibility. The analyses of lifetime and past-month use included all respondents, whereas the analyses of susceptibility included never-users only. All analyses were controlled for age group, sex, race, perceived access to tobacco products, past-month mental health symptoms, past-month alcohol use, and past-month marijuana use as potential confounders (measures are described by McDonell, Comtois, Voss, Morgan, & Ries, 2009). SAS PROC SURVEYLOGISTIC was used to apply the sampling weights.

Results

Among 13,651 US adolescents ages 12–17, 2.3% had visited any tobacco product website. The proportion of adolescents who had visited websites ranged from 0.51% (Camel) to 1.10% (Blu). Inspection of these websites by the authors revealed that Camel website, camel.com, requires strict age verification (i.e., the user must register with a valid name, address, and birthdate to enter the site), whereas the Blu website, blu.com, merely requires the user to click a button labeled, “Yes, I am over 18.”) Among those who had visited any website, 74.0% visited exactly one of the five websites shown; 14.5% had visited two of the websites, and 3.0% had visited all five.

Among the entire sample, 13.4% had ever tried cigarettes, 11.9% had ever tried e-cigarettes, 4.4% had smoked cigarettes in the past month, and 2.9% had used e-cigarette in the past month. Among those who had never tried cigarettes, 32.7% were susceptible to cigarettes. Among those who had never tried e-cigarettes, 34.6% were susceptible to e-cigarettes.

Association between tobacco website exposure and past-month tobacco product use

Table 1 shows the odds ratios and 95% confidence intervals for the associations between viewing tobacco websites and the outcome variables. Unadjusted and adjusted odds ratios are shown. Controlling for covariates, among the entire sample, those who had visited a tobacco website were over 3 times more likely to report lifetime cigarette use, past-month cigarette use, lifetime e-cigarette use, and past-month e-cigarette use.

Table 1.

Associations between viewing nicotine and tobacco product websites and outcome variables

Outcome variable Unadjusted Adjusted1
OR 95% CI OR 95% CI
Lifetime cigarette use 4.1 (3.2, 5.3)* 3.2 (2.3, 4.4)*
Past 30-day cigarette use 4.5 (3.3, 6.2)* 3.2 (2.2, 4.8)*
Lifetime e-cigarette use 4.1 (3.1, 5.4)* 3.2 (2.3, 4.5)*
Past 30-day e-cigarette use 4.4 (2.9, 6.5)* 3.0 (1.9, 4.7)*
Cigarette susceptibility (among never-cigarette-users) 2.9 (2.1, 4.1)* 2.4 (1.7, 3.5)*
E-cigarette susceptibility (among never-e-cigarette-users) 3.4 (2.5, 4.6)* 2.9 (2.1, 4.1)*
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*

p<.0001

1

Adjusted odds ratios are adjusted for age, sex, race, perceived access to tobacco products, past-month mental health symptoms, past-month alcohol use, and past-month marijuana use.

Association between tobacco website exposure and susceptibility among never-users

Among cigarette never-smokers, those who had visited a tobacco website were over 2 times more likely to be susceptible to cigarettes. Among e-cigarette never-users, those who had visited a tobacco website were over 2 times more likely to be susceptible to e-cigarettes.

Discussion

Although only a small proportion of US adolescents are accessing tobacco websites, some adolescents appear to be able to bypass age verification gates. In some cases, accessing these websites might represent a high-risk rule-breaking behavior, which could involve lying about one’s birthdate and/or impersonating an adult family member. This might be a marker for involvement in other risky behaviors. In other cases, adolescents can access these websites by committing a minor untruth—clicking a button agreeing that they are over age 18 or 21. However, the association between website viewing and tobacco product use and susceptibility persisted even after controlling for a mental health screening scale that includes externalizing symptoms such as rule-breaking (McDonell et al., 2009), so it is unlikely that the association is confounded by rule-breaking proclivity.

Once adolescents enter these websites, they have access to tobacco products, advertising, coupons, special offers, contests, and games (Escobedo, in press). Evidence from numerous cross-sectional and longitudinal studies indicates that exposure to cigarette advertising influences nonsmoking adolescents to initiate smoking and progress toward regular smoking (NCI, 2008). This supports the concept that tobacco websites have the potential to encourage tobacco use among adolescents.

Existing legislation against tobacco marketing to youth contains several loopholes. First, regulations against tobacco advertising on broadcast media do not apply to the internet because the internet is not regulated by the Federal Communications Commission (Tobacco Free Kids, 2017). Second, the Master Settlement Agreement, which places further restrictions on youth-oriented tobacco advertising, only applies to the tobacco companies that were involved in the original settlement or joined it later. The companies that sell new products such as e-cigarettes tend to be younger, smaller companies that have not joined the settlement. Historically, tobacco advertising and marketing has targeted adolescents, seemingly attempting to benefit from the sense of maturity and independence that comes along with tobacco use (NCI, 2008). In the last few years, most major tobacco brands have launched websites that do require age verification, however stringency varies greatly, and it may not be difficult to falsify a required birthday or obtain someone else’s log-in information (Campaign for Tobacco Free Kids, 2016). Stronger age verification procedures are needed to prevent adolescents from accessing tobacco websites.

Even though cigarette smoking has been on the decline, youth are beginning to adapt and use more modern products including e-cigarettes. In this study, the highest website viewership was for Blu, a website dedicated solely to e-cigarette use. A recent study on e-cigarette Internet sales to youth showed that minors successfully received purchased e-cigarettes over 75% of the time with no age verification attempts by delivery companies (Williams, Derrick, & Ribisl, 2015). Additionally, nearly all orders were simply left on the doorstep, resulting in a 94% successful buy rate for youth (Williams, Derrick, & Ribisl, 2015).

Limitations

With cross-sectional data, it is impossible to determine whether exposure to tobacco websites leads to tobacco susceptibility and use, or whether youth who are already using tobacco or interested in using tobacco tend to seek out tobacco websites. It is possible that the association between tobacco website exposure and tobacco use is bidirectional adolescents who are curious about tobacco seek out information on the internet, and exposure to that information increases their interest in tobacco. These findings are based on adolescents’ self-reports, which could be inaccurate or biased. The PATH study asked about only five of the many existing tobacco and nicotine product websites. In addition, the PATH study did not ask how many times the adolescents visited the websites.

Conclusions

Despite these limitations, these findings suggest that a small but noteworthy proportion of youth are viewing tobacco advertising online that is ostensibly meant for adults. Increased efforts are needed to prevent adolescents from accessing tobacco websites. Some tobacco companies already restrict access by requiring website visitors to provide a verifiable name, birthdate, and address. In this study, adolescents were twice as likely to visit the website with the laxest age verification procedures (Blu) than the website with the strictest age verification procedures (Camel). Camel’s strict age verification procedures are likely a result of the Master Settlement Agreement, which prohibited tobacco advertising to youth. Now that the FDA regulates other tobacco products such as e-cigarettes, FDA can mandate similar restrictions for new products and brands. Such restrictions are likely to benefit public health.

Highlights.

  • In a nationwide US survey, 2.3% of adolescents had visited tobacco websites.

  • Website visitors were 3.2 times more likely to report past-month cigarette use.

  • Website visitors were 3.0 times more likely to report past-month e-cigarette use.

  • Never-users who visit tobacco websites were more likely to be susceptible to tobacco.

Acknowledgments

Analysis and writing were supported by the University of Southern California Tobacco Center of Regulatory Science (TCORS), funded by the Food and Drug Administration and National Institutes of Health (grant #3P50CA180905). PATH data collection was supported by the National Institutes of Health and the Food and Drug Administration, under a contract to Westat (Contract No. HHSN271201100027C).

Footnotes

Statement 1: Role of Funding Sources

Analysis and writing were supported by the University of Southern California Tobacco Center of Regulatory Science (TCORS), funded by the Food and Drug Administration and National Institutes of Health (grant #3P50CA180905). PATH data collection was supported by the National Institutes of Health and the Food and Drug Administration, under a contract to Westat (Contract No. HHSN271201100027C).

Statement 2: Contributors

Jennifer Unger conceptualized the study, analyzed the data, and contributed to writing. Lauren Bartsch wrote the literature review and contributed to writing the other sections of the paper. Both authors approved the final draft.

Statement 3: Conflict of Interest

The authors report no conflicts of interest.

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