Abstract
Background:
This study examines whether self-reported exposure to cigarette, e-cigarette, cigar, and hookah advertising, and engagement with pro-tobacco and anti-tobacco social media, are associated with past 30-day tobacco use one-year later, among young adults.
Methods:
Data were from two waves of the Marketing and Promotions Across Colleges in Texas study, a multi-wave study of two- and four-year Texas college students (N=3,947; M age=23.3, SD=2.3; 64% female; 35% white, 31% Hispanic, 19% Asian, 8% African-American/black, 7% multi-racial/other) from 24 urban-area schools. Multiple logistic regression examined longitudinal associations between recall of exposure and engagement at baseline (wave 6, spring 2017) and tobacco use at one-year follow-up (wave 7, spring 2018), accounting for baseline demographic characteristics and tobacco use.
Results:
Self-reported exposure to and engagement with tobacco-related social media were significantly associated with past 30-day use of e-cigarettes, cigars, and hookah at one-year follow up; engagement was also associated with cigarette use. Controlling for other social media, exposure to any product advertising via Reddit increased risk for e-cigarette use (AOR=1.92 [95% CI: 1.17–3.14]). Pinterest exposure increased risk for cigar use (2.92 [1.24–6.85]). Snapchat exposure increased risk for hookah use (2.94 [1.70–5.11]). Pro-tobacco engagement increased risk for future use of all products (1.77 [1.29–2.42]). Anti-tobacco engagement increased risk for use of cigars (1.59 [1.12–2.27]) and hookah (1.69 [1.27–2.25]).
Conclusions:
Findings demonstrate that encountering tobacco-related social media is an important risk factor for future tobacco use among young people. Social media should be a focus of federal regulation, counter-marketing and health communication campaigns, and intervention.
Keywords: Electronic cigarettes, Marketing, Social media, Tobacco use, Young Adults
1. Introduction
The rapid evolution of electronic cigarette (e-cigarette) use, especially among young people, has led to new and urgent public health problems. In 2019, the Centers for Disease Control and Prevention reported a number of cases of lung disease and death in the U.S. associated with e-cigarette or vaping product use; the number continues to grow (Centers for Disease Control and Prevention [CDC], 2019b). This follows the U.S. Surgeon General’s advisory that e-cigarette use is not harmless (CDC, 2019c) and contemporary research showing e-cigarette use may lead to future cigarette use (Barrington-Trimis et al., 2018; Clendennen, Loukas, Creamer, Pasch, & Perry, 2019). Extensive research shows tobacco industry marketing is a major driving force of the tobacco epidemic (Davis, Gilpin, Loken, Viswanath, & Wakefield, 2008). Since tobacco advertising on television, billboards, transit media, and other outdoor venues has been restricted, tobacco companies have increased promotion through the internet and social media (Kim, Arnold, & Makarenko, 2014). Social media in particular is an ideal platform for tobacco promotion since social media are inexpensive, underregulated, and widely popular among young people (Jackler, Li, Cardiff, & Ramamurthi, 2018; Yamin, Bitton, & Bates, 2010). Studies show social media including Facebook, YouTube, Twitter, and Instagram are popular venues for tobacco brand pages, especially cigarettes and e-cigarettes, and sales promotion via these pages is widespread (Allem, Dharmapuri, Unger, & Cruz, 2018; Clendennen, Vandewater, Loukas, Perry, & Wilkinson, 2020; McCausland, Maycock, Leaver, & Jancey, 2019).
Tobacco brand-generated content on social media exploits themes of social acceptability, offers coupons and price promotions, and communicates unsubstantiated health claims (Huang, Kornfield, Szczypka, & Emery, 2014; Vandewater et al., 2018). User-generated content, such as peer posts about tobacco and vape trick videos, is also prevalent on social media (Brett et al., 2019; Hébert et al., 2017; Unger et al., 2018). Since young adults, ages 18–29, in the U.S. have the highest rates of tobacco use, and 90% of young adults use, interact with, and seek information on social media daily (Emery, Vera, Huang, & Szczypka, 2014; Link, Cawkwell, Shelley, & Sherman, 2015; Pew Research Center [PRC], 2018), social media is an important potential source of exposure to and engagement with tobacco-related messaging for young adults. Previous research has demonstrated significant, cross-sectional associations between viewing social media peer posts and advertisements about e-cigarettes (Sawdey, Hancock, Messner, & Prom-Wormley, 2017), and having more e-cigarette users in one’s social network (Pokhrel et al., 2018), and past 30-day e-cigarette use, among college students (n=258 and 470, respectively). Depue, Southwell, Betzner, & Walsh (2015) demonstrated a significant, longitudinal (5-month follow-up) association between self-reported exposure to tobacco use in social media and past 30-day cigarette use, among 200 young adults.
Among adolescents, Hébert et al. (2017) found that 52.5% of middle and high school students in urban Texas reported past 30-day exposure to tobacco-related social media, and 5.7% reported engaging (posting videos or pictures of vape tricks, writing, responding to, or re-blogging about tobacco or e-cigarettes). Students susceptible to using combustible tobacco and e-cigarettes were significantly more likely to report exposure. Soneji et al. (2017b) estimated that 2.9 million (12%) U.S. adolescents, ages 12–17 years, engage with online tobacco marketing (sign up for e-mail alerts about tobacco, like or follow tobacco brands on social media, play online tobacco-related games, etc.), and reported significant associations between engagement with online tobacco marketing and susceptibility to using tobacco among a nationally representative sample (N=13,651) from the Population Assessment of Tobacco and Health (PATH) study. Soneji et al. (2018) extended this research, showing engagement increased the risk of tobacco use initiation, increased frequency of use, progression to multiple product use, and decreased likelihood of cessation. Choi, Rose, Zhou, Rahman, & Hair (2019) reported adolescents from PATH (N=10,081) who reported receiving tobacco coupons (9.7%) and engaging with online tobacco marketing (11.1%) during the previous 6 months were likely to report past 30-day use of e-cigarettes, cigars, smokeless tobacco, and hookah, two years later. Taken together, these studies show that encountering tobacco-related social media is an important risk factor for tobacco use among young people. However, more research is needed, especially among young adults who are the youngest legal targets of tobacco industry marketing (Ling & Glantz, 2002) and report the highest use of tobacco and social media, compared to other age groups (PRC, 2018).
1.1. Study Aims
The purpose of this study was to extend previous research by estimating the longitudinal associations between self-reported exposure to cigarette, e-cigarette, cigar, and hookah advertising, as well as engagement with pro- and anti-tobacco-related social media, and subsequent tobacco use among a large, diverse sample of young adults, one year later. To date, no study has examined these associations among a large, demographically diverse sample of young adults. Further, no study has examined product-specific exposures via a wide array of increasingly popular social media including Snapchat, Pinterest, and Reddit. In addition, previous studies have been limited by examining engagement via one or two types, and engagement among young adults and with anti-tobacco messaging have not been examined.
2. Methods
2.1. Sample
Participants were from the Marketing and Promotions Across Colleges in Texas study (Project M-PACT), a surveillance study of college students’ tobacco use behaviors. A cohort of 5,482 students, ages 18–29, attending one of 24 colleges in Texas was established in November 2014 through February 2015 (wave 1), and surveyed every six months through April-May 2017 (wave 6), and then one year later in April-May 2018 (wave 7). Participants in the current analysis participated in data collection in April-May 2017 (wave 6) and again in April-May 2018 (wave 7), as detailed questions regarding students’ exposure to and engagement with tobacco-related social media were introduced at wave 6.
2.2. Procedure
Twenty-four colleges were recruited from five counties surrounding the four largest metropolitan areas in Texas (Austin, Dallas/Fort Worth, Houston, and San Antonio). Three two-year and three four-year colleges were selected from each area. Eligible students were 18–29 years of age and full- or part-time degree- or certificate-seeking undergraduate students at a participating four-year college or enrolled in a vocational program at a two-year college. Eligible students who agreed to participate provided informed consent, then completed an online survey. A total of 13,714 students were eligible to participate, of whom 5,482 (40%) provided consent and completed the baseline (wave 1) survey. At wave 6, 4,384 students participated (an 80% retention rate), and of those 3,947 (90%) participated one-year later at wave 7. Participants received a $20 electronic gift card at both waves, and all students were entered into a drawing to win one of 20 $50 gift cards at wave 6, and one of 80 $25 gift cards at wave 7. Further details regarding Project M-PACT procedures were published by Creamer et al. (2018) and Loukas et al. (2016). Hereafter, wave 6 and wave 7 are referred to as baseline and one-year follow-up, respectively.
2.3. Measures
Project M-PACT measures were modeled after existing surveys (CDC, 2019a; National Institutes of Health [NIH], 2018) and reviewed by nine tobacco control experts. Final item modifications were conducted through an iterative process of cognitive interviewing with 25 young adults who were not Project M-PACT participants (Hinds III et al., 2016).
2.3.1. Exposure to Social Media Tobacco Advertising
At baseline, participants were asked, “During the past 30 days, how often did you see any advertisements for [product] on [social media platform]?” Products assessed included cigarettes; electronic nicotine delivery system (ENDS) devices (i.e., electronic cigarettes (e-cigarettes), vape pens); cigar products; and hookah/waterpipe. Social media platforms assessed included the most used social media by U.S. young adults: Facebook, Instagram, YouTube, Twitter, Snapchat, Reddit, and Pinterest (PRC, 2018). Response options ranged from “Never” to “Very Frequently” on a 5-point scale. Consistent with previous research (Depue et al., 2015; Hébert et al., 2017; Sawdey et al., 2017) exposure was dichotomized into students who reported zero exposure and students who reported any exposure. Exposure was examined by social media platform (e.g., exposure to any product advertising on Facebook, or on YouTube, etc.), and by product (e.g., exposure to cigarette, or e-cigarette, etc. advertising on any social media).
2.3.2. Engagement with Social Media Tobacco Messaging
Six forms of tobacco engagement were assessed at baseline: (1) posting links to tobacco product websites, stories, or articles, (2) posting comments about tobacco use, (3) encouraging other people to use or discouraging other people from using tobacco products, (4) posting about personal tobacco use, (5) reposting tobacco-related content that was originally posted by someone else, and (6) visiting, following, or liking tobacco products on social media. Tobacco engagement was dichotomized into students who reported zero engagement and students who reported any engagement. Four engagement outcomes were assessed: any tobacco engagement, total tobacco engagement, anti-tobacco engagement, and pro-tobacco engagement. Any tobacco engagement was defined as reporting engagement via at least one of the six forms of engagement, such that 0 = never engage and 1 = engage in one or more ways. Total number of tobacco engagement activities was examined via a count ranging from 0 = participated in zero forms of engagement to 6 = participated in six forms of engagement.
To assess pro-tobacco and anti-tobacco engagement, we asked about engagement with “pro-tobacco” and “anti-tobacco” content. “Pro-tobacco” was defined as any website, social media page, advertisement, post, video, or image that encourages tobacco or nicotine product use or shows tobacco use to be a positive behavior. “Anti-tobacco” was defined as any website, social media page, advertisement, post, video, or image that discourages tobacco use and shows it to be a negative behavior.
Anti-tobacco engagement was defined as reporting engaging via posting links to anti-tobacco product websites, stories, or articles; posting comments about the negative aspects of tobacco use; and/or discouraging other people from using tobacco, such that 0 = never engage in any of the three anti-tobacco engagement activities and 1 = engage in at least one of the three anti-tobacco engagement activities.
Pro-tobacco engagement was defined as reporting engaging via posting links to pro-tobacco product websites, stories, or articles; posting comments about the positive aspects of tobacco use; and/or encouraging other people to use tobacco, such that 0 = never engage in any of the three pro-tobacco engagement activities and 1 = engage in at least one of the three pro-tobacco engagement activities.
2.3.3. Current Use of Tobacco
At baseline and one-year follow-up, current use of cigarettes, cigar products, electronic nicotine delivery system (ENDS) devices (i.e., electronic cigarettes (e-cigarettes), vape pens), and waterpipe/hookah was assessed by asking, “On how many days of the past 30 days did you smoke/use [product]?” Students who reported use on at least one day in the past 30 days were considered current (past 30-day) users, and those who reported use on zero days in the past 30 days were considered non-current users. For cigars, hookah, and e-cigarettes, language regarding using the product “as intended” was added to make it clear the questions were asking about use of the product with tobacco or nicotine, and not another substance (e.g., marijuana).
2.3.4. Covariates
Covariates included baseline age, biological sex (male and female), and race/ethnicity (non-Hispanic white, Hispanic\Latino, Asian, African American\black, multi-racial or another race/ethnicity). Any baseline tobacco use (items described above) was also included as a covariate and coded 0 = used zero products in the past 30 days at baseline or 1 = used at least one product in the past 30 days at baseline.
2.4. Analysis
Multiple logistic regression analyses were used to examine associations between self-reported exposure to and engagement with tobacco-related social media at baseline and tobacco and nicotine product use at one-year follow-up. The longitudinal associations between (1) any exposure, and (2) exposure by social media platform and use of (1) cigarettes, (2) e-cigarettes, (3) cigars and (4) hookah were assessed. Likewise, longitudinal associations between (1) any engagement, (2) total number of engagement activities, (3) anti-tobacco engagement, and (4) pro-tobacco engagement and use of (1) cigarettes, (2) e-cigarettes, (3) cigars and (4) hookah were assessed. All models controlled for baseline age, sex, race/ethnicity, and baseline tobacco use. When examining the effects of exposure by social media platform, models additionally controlled for other social media platforms (e.g., the association between baseline Facebook exposure and future cigarette use was assessed controlling for baseline exposure via YouTube, Instagram, etc.). Missing data for each model ranged from 0.50% - 3.06%. Missing data were handled using listwise deletion for each model since analyses with complete cases and analyses with missing data did not yield different results.
2.5. Ethical Approval
Project M-PACT was reviewed and approved by the University of Texas at Austin Institutional Review Board (2013–06-0034). The present study was approved by the University of Texas Health Science Center Institutional Review Board (HSC-SPH-16–0994).
3. Results
3.1. Sample Characteristics
Shown in Table 1, participants were 20–32 years of age (M = 23.3; SD = 2.3) at baseline in spring 2017. The majority of participants were female (64.8%) and four-year university students (93.1%). Participants were 35.4% non-Hispanic white, 30.6% Hispanic, 18.7% Asian, 7.8% non-Hispanic black, and 7.5% multi-racial/ethnic or another race/ethnicity. Between baseline and one-year follow-up, lifetime (ever) use of tobacco and nicotine products increased slightly, by 1.8%, with the greatest initiation of cigar use (2.1%), followed by e-cigarettes (2.0%), and cigarettes (1.6%) and hookah (1.6%). Past 30-day (current) use increased very slightly between baseline and one-year follow-up, by 0.6%. Current cigarette, hookah, and cigar use decreased by 1.5%, 1.0%, and 0.2%, respectively. Only current e-cigarette use increased by 3.5%.
Table 1.
Characteristics of the Study Population (M-PACT study, N = 3,947).
| Variable | Baseline (Spring 2017) % (n) or M (SD) | One-year Follow-up (Spring 2018) % (n) or M (SD) | ||
|---|---|---|---|---|
|
| ||||
| Age, M (SD) | 23.3 | (2.3) | 24.3 | (2.3) |
| Female, % (n) | 64.8 | (2,557) | 64.8 | (2,557) |
| Race/ethnicity, % (n) | ||||
| Non-Hispanic white | 35.4 | (1,397) | 35.4 | (1,397) |
| Hispanic | 30.6 | (1,209) | 30.6 | (1,209) |
| Asian | 18.7 | (736) | 18.7 | (736) |
| African American/black | 7.8 | (309) | 7.8 | (309) |
| Other | 7.5 | (296) | 7.5 | (296) |
| Four-year University Student, % (n) | 93.1 | (3,675) | 93.1 | (3,675) |
| Lifetime Tobacco Product Use, % (n) | ||||
| Any product | 74.9 | (2,957) | 76.7 | (3,027) |
| Cigarettes | 53.9 | (2,126) | 55.5 | (2,191) |
| E-cigarettes | 57.4 | (2,265) | 59.4 | (2,344) |
| Hookah | 66.9 | (2,641) | 68.5 | (2,703) |
| Cigars | 47.3 | (1,866) | 49.4 | (1,951) |
| Past 30-day Tobacco Product Use, % (n) | ||||
| Any product | 26.2 | (1,033) | 26.8 | (1,057) |
| Cigarettes | 15.7 | (619) | 14.2 | (569) |
| E-cigarettes | 8.6 | (340) | 12.1 | (478) |
| Hookah | 8.9 | (353) | 7.9 | (313) |
| Cigars | 5.2 | (204) | 5.0 | (199) |
M = mean, SD = standard deviation.
Female, Race/ethnicity and Four-year University Student were assessed at wave 1 (November 2014 - February 2015) only.
3.2. Prevalence of Exposure and Engagement with Tobacco-Related Social Media
Overall, 29.1% of participants reported seeing advertisements for tobacco and nicotine products on social media during the past 30 days at baseline. Exposure to tobacco advertising was greatest on Facebook, then Instagram, YouTube, Twitter, Snapchat, Reddit, and Pinterest. Participants reported seeing more advertising for e-cigarettes, followed by cigarettes, hookah, and cigars. Overall, 22.9% of participants reported ever engaging with social media tobacco messaging at baseline. Prevalence of engagement with anti-tobacco related content was greater than engagement with pro-tobacco content, 18.6% and 6.7%, respectively. The mean number of engagement activities (ranging from 0–6) for the sample was 0.49 (Table 2).
Table 2.
Prevalence of Exposure to and Engagement with Social Media Tobacco Messaging at Baseline (M-PACT studv. N = 3,947).
| Variable | % (n) or M (SD) | |
|---|---|---|
|
| ||
| Past 30-day Recall of Marketing Exposure, % (n) | ||
| Any product on any social media | 29.1 | (1,147) |
| By Social Media Platform | ||
| 22.0 | (870) | |
| 14.5 | (572) | |
| YouTube | 13.1 | (518) |
| 9.9 | (392) | |
| Snapchat | 8.9 | (353) |
| 7.8 | (308) | |
| 6.6 | (259) | |
| By Tobacco Product | ||
| E-cigarettes | 19.9 | (785) |
| Cigarettes | 18.2 | (717) |
| Hookah | 14.0 | (551) |
| Cigars | 8.8 | (349) |
| Lifetime Recall of Engagement with Tobacco Messaging, % (n) | ||
| Any engagement | 22.9 | (905) |
| No. engagement activities (range 0–6), M (SD) | 0.49 | (1.1) |
| Anti-engagement | 18.6 | (734) |
| Pro-engagement | 6.7 | (264) |
M = mean, SD = standard deviation.
3.3. Exposure and Associations with Tobacco Use
As shown in Table 3, logistic regression analyses revealed significant associations between self-reported exposure to tobacco-related social media advertising and current (past 30-day) tobacco use outcomes one year later. After controlling for age, sex, race/ethnicity, and any current tobacco use at baseline, exposure to any product advertising on social media was significantly associated with use of e-cigarettes (AOR: 1.33, 95% CI: 1.06 – 1.66), cigars (AOR: 1.68, 95% CI: 1.24 – 2.28), and hookah (AOR: 1.71, 95% CI: 1.33 – 2.20) at one-year follow-up, but not cigarette use. Controlling for age, sex, race/ethnicity, baseline current tobacco use, and exposure via other platforms, the odds of e-cigarette use at follow-up were 1.92 (95% CI: 1.17 – 3.14) times higher among students who were exposed to product advertising on Reddit at baseline, compared to those who were not exposed via Reddit. The odds of cigar use were 2.92 (95% CI: 1.24 – 6.85) times higher among students exposed via Pinterest. The odds of hookah use were 2.94 (95% CI: 1.70 – 5.11) times higher among students exposed via Snapchat.
Table 3.
Logistic Regressions of Social Media Tobacco Exposure Predicting Past 30-day Tobacco Use at One-year Follow-up.
| Cigarette Use | E-Cigarette Use | Cigar Use | Hookah Use | |
|---|---|---|---|---|
| Type of exposure | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) |
|
| ||||
| Any Exposurea | 1.12 (0.90 – 1.39) | 1.33 (1.06 – 1.66)* | 1.68 (1.24 – 2.28)** | 1.71 (1.33 – 2.20)*** |
| Exposure By Platformb | ||||
| 0.86 (0.63 – 1.19) | 1.09 (0.79 – 1.50) | 1.23 (0.78 – 1.97) | 0.99 (0.67 – 1.44) | |
| YouTube | 1.08 (0.71 – 1.63) | 1.22 (0.81 – 1.84) | 0.77 (0.40 – 1.48) | 1.10 (0.68 – 1.76) |
| 1.26 (0.83 – 1.91) | 0.92 (0.60 – 1.40) | 0.62 (0.32 – 1.23) | 1.42 (0.89 – 2.26) | |
| 0.75 (0.45 – 1.24) | 1.10 (0.67 – 1.79) | 1.56 (0.78 – 3.13) | 0.73 (0.42 – 1.28) | |
| Snapchat | 0.90 (0.51 – 1.61) | 0.70 (0.38 – 1.28) | 1.20 (0.53 – 2.75) | 2.94 (1.70 – 5.11)*** |
| 1.48 (0.90 – 2.43) | 1.92 (1.17 – 3.14)** | 1.38 (0.71 – 2.70) | 0.85 (0.46 – 1.56) | |
| 1.67 (0.88 – 3.17) | 0.98 (0.50 – 1.92) | 2.92 (1.24 – 6.85)* | 1.40 (0.71 – 2.78) | |
AOR = adjusted odds ratio; CI = confidence interval; N for each model ranged from 3,826 – 3,947.
Current (past 30-day) tobacco and nicotine product users are being compared to non-current users, which may include ever/lifetime users.
Models adjusted for age, sex, race/ethnicity, and baseline any current tobacco use.
Models adjusted for age, sex, race/ethnicity, baseline any current tobacco use, and other platform exposure.
p < .05;
p < .01;
p < .001
3.4. Engagement and Associations with Tobacco Use
As shown in Table 4, logistic regression analyses revealed significant associations between engagement with tobacco-related social media and current (past 30-day) tobacco use outcomes one year later. After controlling for age, sex, race/ethnicity, and any current tobacco use at baseline, engagement in any form was significantly associated with use of e-cigarettes, cigars, and hookah, at one-year follow-up. For each additional engagement activity reported at baseline, the odds of any product use at follow-up increased between 1.12 (95% CI: 1.04 – 1.21) and 1.30 (95% CI: 1.18 – 1.42). Students who engaged with pro-tobacco content on social media at baseline were significantly more likely to report current use of all tobacco products at one-year follow-up. Students who engaged with anti-tobacco content on social media at baseline were significantly more likely to currently use cigars and hookah at one-year follow-up.
Table 4.
Logistic Regressions of Social Media Tobacco Engagement Predicting Past 30-day Tobacc Use at One-year Follow-up.
| Cigarette Use | E-cigarette Use | Cigar Use | Hookah Use | |
|---|---|---|---|---|
| Type of engagement | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) | AOR (95% CI) |
|
| ||||
| Any Engagement | 1.15 (0.91 – 1.45) | 1.33 (1.05 – 1.68)* | 1.47 (1.06 – 2.03)* | 1.69 (1.30 – 2.20)*** |
| No. Engagement Activities (range: 0–6) Anti-engagement |
1.12 (1.04 – 1.21)** 1.16 (0.89 – 1.50) | 1.12 (1.04 – 1.21)** 1.16 (0.89 – 1.51) | 1.30 (1.18 – 1.42)*** 1.59 (1.12 – 2.27)** | 1.28 (1.18 – 1.38)*** 1.69 (1.27 – 2.25)*** |
| Pro-engagement | 1.78 (1.28 – 2.48)*** | 1.45 (1.03 – 2.04)* | 2.92 (1.95 – 4.37)*** | 2.37 (1.67 – 3.36)*** |
AOR = adjusted odds ratio; CI = confidence interval; N for each model ranged from 3,826 – 3,947.
Current (past 30-day) tobacco and nicotine product users are being compared to non-current users, which may include ever/lifetime users. All models adjusted for age, sex, and race/ethnicity, and baseline any current tobacco use.
p < .05;
p < .01;
p < .001
4. Discussion
This study is the first to examine longitudinal associations between self-reported exposure to and engagement with an array of tobacco products on popular social media and use of these products among young adult college students. Almost one third of young adults in our sample reported exposure to tobacco product advertising on social media in the past month, and one quarter engaged with tobacco-related social media. These exposures and engagements have implications for tobacco use. We found both exposure and engagement significantly increased the odds of past 30-day e-cigarette, cigar, and hookah use one year later, after controlling for important demographic characteristics and any current tobacco use at baseline. Given that so many young adults use tobacco and that young adulthood is a time where there continue to be changes in tobacco use patterns (Clendennen et al., 2019; Perry et al., 2018), we need to move to regulate social media and provide messages to young adults about the impact of social media on their tobacco use.
This study extends previous research by examining the associations between exposure by social media platform and use behaviors. After controlling for demographic characteristics, baseline current tobacco use, and exposure to all other social media, exposure via Reddit was associated with subsequent e-cigarette use, Pinterest exposure was associated with cigar use, and Snapchat exposure with hookah use. Several studies have demonstrated that Reddit is heavily used by e-cigarette companies to sell products and share information (Barker & Rohde, 2019; Wang et al., 2015). In a previous study we found that recall of hookah advertising was more prevalent on Snapchat, relative to other tobacco products (Clendennen et al., 2020). These findings reveal that specific social media may be more popular venues for promoting certain products, and use of these social media platforms may be an important risk factor for use of a particular product. As such, counter-marketing communications and interventions about e-cigarettes should consider utilizing Reddit; cigar and hookah prevention efforts should consider utilizing Pinterest and Snapchat, respectively. Future studies should investigate the nature of tobacco promotion across various social media, especially as new social media emerge, to better understand why and how specific social media is associated with specific product use.
This study also found significant, prospective associations between several measures of engagement with tobacco-related social media and subsequent use behaviors one year later. No study to date has examined these associations among young adults. Our findings echo those of Hébert et al. (2017) and Soneji et al. (2017a) who both reported cross-sectional significant associations between engagement and tobacco use among youth. Our findings build upon previous studies: engagement with tobacco-related social media was a significant risk factor for later use of tobacco and nicotine products, and higher levels of engagement were associated with increased risk of use. Further, this study is the first to examine the association between engagement with anti-tobacco messaging on social media and tobacco use. Those who engaged with anti-tobacco social media, compared with those who did not engage, were not more likely to use cigarettes or e-cigarettes one year later. These null findings may be due to our inability to assess anti-tobacco engagement by product, and future research might better ascertain the individual associations between anti-cigarette engagement and e-cigarette use and anti-e-cigarette engagement and cigarette use. However, anti-tobacco engagement did increase risk for future cigar and hookah use. One potential explanation for these findings is that cigar and hookah users perceive these products to be less harmful than cigarettes and e-cigarettes (Getachew et al., 2018; Osibogun, Taleb, Bahelah, Salloum, & Maziak, 2018; Roberts, Klein, Berman, Berhane, & Ferketich, 2017) and thus may engage in anti-cigarette or e-cigarette messaging. Future research should identify reasons (whether harm perceptions or others reasons) why users of one product may engage in anti-messaging for another product.
This study has some limitations. First, the study sample was limited to students attending colleges within five Texas counties; thus, study findings are not generalizable to other populations. However, the study sample included students from both two- and four-year colleges and is racially and ethnically diverse. This is an important distinction of our study since two-year college students are more likely to use tobacco and be racial/ethnic minority students, compared to four year college students and other adult populations (Biener, McCausland, Curry, & Cullen, 2011; Loukas, Murphy, & Gottlieb, 2008). However, over 90% of our sample was from four-year universities and was majorly female. Future studies should incorporate more diverse young adult populations to investigate these relationships. Second, data are subject to recall bias since all measures were collected via self-report. More research is needed to investigate whether respondents can accurately report their exposures by social media platform. Finally, it is possible that students differentially defined exposure and engagement. Participants were asked to report about tobacco product advertising on social media. It is possible that participants were reporting seeing anti-tobacco advertisements or user-generated content such as peer posts, as well as tobacco company advertisements. However, given the lack of regulation of social media tobacco product advertising, it may be difficult to distinguish the exact nature of tobacco-related content, whether user- or brand-generated. Thus, more research is needed to investigate the nature of young adults’ exposure and engagement with this content, especially as newly emerging ENDS products, such as JUUL are heavily utilizing social media to market their products (Huang et al., 2018). We also asked about engagement with any tobacco product, so we were not able to clearly distinguish between engagements with specific products. It may be important for future studies to distinguish between cigarette and e-cigarette engagement since students may be avid e-cigarette users and promoters, while heavily engaging in anti-cigarette social media content, for example. Our measures did not allow us to investigate these distinctions.
Despite limitations, this study has important strengths and implications for regulation and intervention. The present study found young adults’ exposure and engagement with tobacco-related social media, including industry-sponsored advertising, increase risk of future past 30-day tobacco use one year later, after controlling for several other important influencing factors. In this study, we examined current (past 30-day) use versus non-current use. Notably, non-current users may include ever users, yet we still observed significant associations between exposure and engagement and tobacco use behaviors. These findings, taken with the knowledge that social media is an integral part of young adult life, indicate that social media should be a focus of future federal regulation, counter-marketing and health communication campaigns, and intervention. Although the marketing of tobacco products through television, billboards, and other venues is prohibited, there are no federal laws prohibiting or regulating marketing via social media (US Food and Drug Administration [FDA], 2018). While most popular social media platforms have policies restricting sponsored tobacco product advertising, promotion via brand pages is permitted, and recent studies have shown these self-imposed policies are ineffective (Jackler et al., 2018). Future potential regulations include having tobacco brands register their social media accounts so that these accounts can be monitored for inappropriate content like making unsubstantiated health claims. Another potential regulation is to require brand-sponsored pages to be made private (i.e., content is visible only to followers), and to only allow verified users, ages 21 years and older, to follow brand pages. Currently, many brand social media accounts are public, so their content may be viewed and shared by anyone. Finally, brand-sponsored posts, images, and videos could be required to contain warning labels about the health effects of the products advertised. In addition, this study highlights the critical need for counter-marketing campaigns that utilize social media tools for engaging young people in viewing and sharing relevant information about the addictive nature of nicotine, and the negative health effects of combustible tobacco. In a recent study that evaluated youth and young adults’ preferences for online tobacco education, participants recommended social media as a way to engage them in tobacco communications (Lazard et al., 2018). Future research is needed to investigate the nature and source of young peoples’ exposure to and engagement with tobacco-related social media to better inform regulation and prevention efforts.
Highlights.
One-third of young adults reported past 30-day exposure to social media tobacco advertising.
One-fourth of young adults reported ever engaging with tobacco-related social media.
Engagement with anti-tobacco messaging was more prevalent than pro-engagement.
Exposure and engagement were significantly associated with subsequent tobacco use.
Role of the funding source
This work was supported by grant number (1 P50 CA180906) from the National Cancer Institute and the FDA Center for Tobacco Products (CTP). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.
Footnotes
Conflict of interest
The authors have no conflicts of interest to declare.
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