Youth Exposure and Response to the FDA Health Warning Label on Electronic Cigarettes Packaging: Poli

Asfar T, Oluwole OJ, Pan Y, Casas A, Hernandez Garayua AM, Schmidt M, Noar SM.
Youth Exposure and Response to the FDA Health Warning Label on Electronic Cigarettes Packaging: Policy Implications
Nicotine Tob Res. 2023 Sep 9:ntad175. doi: 10.1093/ntr/ntad175. Epub ahead of print. PMID: 37688562.

Introduction. Youth represent a high-priority group for e-cigarette health communication. This study examined youth exposure to the FDA e-cigarette warning label over four years and its association with change in youth harm perception and intention.

Methods. We pooled data from the 2018-2021 National Youth Tobacco Survey (age 10-17; n=67,159). Participants were divided into four groups: never users (58.5%), susceptible nonusers (16.3%), former users (12.7%), and current users (12.5%). We examined the prevalence, time-trend, correlates, and association of youth exposure to the warning with addictiveness and harm perception, intention to use e-cigarettes, and intention to quit all tobacco products.

Results. Only 24.5% of youth were exposed to the warning. Exposure increased from 14.9% in 2018 to 30.8% in 2019, then declined to 25.2% in 2021. Hispanic (aOR=0.76 [95 % CI=0.641 - 0.89]) and non-Hispanic Black current users (0.53 [0.40 - 0.69]) were less likely to be exposed to the warning than White current users. Youth exposure was positively associated with a higher perception of e-cigarette addictiveness (1.12 [1.04 - 1.19]) and intention to quit all tobacco products (1.28 [1.13 - 1.46]). However, exposure was negatively associated with harm perception (0.91 [0.85 - 0.96]) and intention to use e-cigarettes among e-cigarette nonusers (2.38 [1.99 - 2.84]).

Conclusions. The decline in youth exposure to the warning indicates wear-out effects. Strengthening the label by using compelling designs, adding themes on e-cigarette harm to youth, periodically rotating warning content, and using culturally tailored messaging may improve its impact on youth and address the racial/ethnic disparities.

Implications. The FDA e-cigarette label reached only 24.5% of youth, and exposure to the warning declined to indicate wear-out effects. Exposure was significantly lower among minorities. Exposure was associated with a higher perception of e-cigarette addictiveness and intention to quit all tobacco products. Still, it did not increase harm perception or reduce intention to use e-cigarettes among nonusers. Strengthening the label by using more compelling designs, including diverse themes focusing on e-cigarette harm relevant to youth, and periodically rotating warning content may improve its impact on youth. Continued surveillance of the implementation of e-cigarette policies is needed to ensure that they equally affect youth across racial/ethnic subpopulations.