Considerations and Future Research Directions for E-Cigarette Warnings—Findings from Expert Interviews
Abstract
:1. Introduction
2. Materials and Methods
2.1. Participants and Recruitment
2.2. Procedures and Stimulus Materials
2.3. Analysis
3. Results
3.1. Perceptions of the FDA’s Nicotine Addiction Warning
3.1.1. Perceived Strengths
“…certainly there’s a large number of adolescents who don’t understand that e-cigarettes contain nicotine, so the idea that there be a clear warning is good.”
3.1.2. Potential Limitations
3.2. Other Warning Concepts
“We need to really clearly think through who are our target audiences and what do we need to do to attract their interest because if they don’t see this message as being relevant to them, then it’s not going to resonate no matter how factually accurate it is. And can this all be done with a single warning message? Very unlikely.”
3.2.1. Other Nicotine Effects
3.2.2. Chemicals and Constituents
3.2.3. Explosion Risk
3.2.4. Cessation-Related
3.3. Potential Advantages of Pictorial and Colored Warnings
“we’re helping people to at least pay attention to the messages, to remember them, hopefully remember them over time. And really it’s imagery that helps people do that. So I would say absolutely use images.”
“…we do a lot of things in black and white, but you know safety orange conveys a message, other bright colors convey warning. People associate those colors with danger and warning. And so there may be some interesting variations that could be done that would make it much more visible and would stand out….”
3.4. Warning Placement and Exposure
“You know [this] speaks to the importance of making sure that if the warnings are on the packaging, the packaging that will be disposed of … that you make sure that they are as noticeable and salient as possible because you’re just not going to get the same level of exposure [as with cigarette warnings].”
3.5. Reduced-Risk Warnings
“I think simply using the warning label or that area for endorsing the product, that’s not the right purpose for the warning. The ‘safer product’ could be done with the communications from the company, the advertisements ….”
“Because people don’t know risk. I mean risk is probabilistic … you know, risk is like “oh it might happen, it might not”. Harm, that’s an outcome. Risk is not an outcome.”
“…I think the emphasis needs to fall on you know ‘these products may be less harmful, but they’re harmful’. I mean I think the emphasis will always fall on communicating a level of harm as the primary message and the secondary one giving some relative-risk compared to cigarettes. So you know I think the Swedish Match warning doesn’t do that.”
“I think that would be something really valuable for the FDA to know about … and necessary for us to kind of build the evidence base for what might be a sensible approach. And if not for FDA, which might have their hands tied, for other governments throughout the world where there might be greater flexibility.”
“In most other countries, cigarettes have bigger warnings and they have pictures, whereas smokeless products do not. And so irrespective of any relative-risk content, it is true that consumers perceive the size of warnings as an indicator of the severity of risks. So I think there are ways of doing that through the design of the warning.”
4. Discussion
5. Conclusions
Acknowledgments
Author Contributions
Conflicts of Interest
References
- Hammond, D. Health warning messages on tobacco products: A review. Tob. Control 2011, 20, 327–337. [Google Scholar] [CrossRef] [PubMed]
- Hammond, D. Tobacco packaging and labeling policies under the US Tobacco Control Act: Research needs and priorities. Nicotine Tob. Res. 2012, 14, 62–74. [Google Scholar] [CrossRef] [PubMed]
- Noar, S.M.; Hall, M.G.; Francis, D.B.; Ribisl, K.M.; Pepper, J.K.; Brewer, N.T. Pictorial cigarette pack warnings: A meta-analysis of experimental studies. Tob. Control 2016, 25, 341–354. [Google Scholar] [CrossRef] [PubMed]
- Noar, S.M.; Francis, D.B.; Bridges, C.; Sontag, J.M.; Ribisl, K.M.; Brewer, N.T. The impact of strengthening cigarette pack warnings: Systematic review of longitudinal observational studies. Soc. Sci. Med. 2016, 164, 118–129. [Google Scholar] [CrossRef] [PubMed]
- Shang, C.; Chaloupka, F.J. The trend of voluntary warnings in electronic nicotine delivery system magazine advertisements. Int. J. Environ. Res. Public Health 2017, 14, 62. [Google Scholar] [CrossRef] [PubMed]
- McNeill, A.; Brose, L.S.; Calder, R.; Hitchman, S.C.; Hajek, P.; McRobbie, H. E-Cigarettes: An Evidence Update (A Report Commissioned by Public Health England). Available online: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf (accessed on 31 May 2017).
- Royal College of Physicians. Nicotine without Smoke—Tobacco Harm Reduction. 2016. Available online: https://www.rcplondon.ac.uk/projects/outputs/nicotine-without-smoke-tobacco-harm-reduction-0 (accessed on 31 May 2017).
- U.S. Department of Health and Human Services. E-Cigarette Use among Youth and Young Adults. A Report of the Surgeon General; U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health: Atlanta, GA, USA, 2016.
- Glasser, A.M.; Collins, L.; Pearson, J.L.; Abudayyeh, H.; Niaura, R.S.; Abrams, D.B.; Villanti, A.C. Overview of electronic nicotine delivery systems: A systematic review. Am. J. Prev. Med. 2017, 52, e33–e66. [Google Scholar] [CrossRef] [PubMed]
- Chen, J.; Bullen, C.; Dirks, K. A comparative health risk assessment of electronic cigarettes and conventional cigarettes. Int. J. Environ. Res. Public Health 2017, 14, 382. [Google Scholar] [CrossRef] [PubMed]
- Food and Drug Administration. Deeming Tobacco Products to Be Subject to the Federal Food, Drug, and Cosmetic Act, as Amended by the Family Smoking Prevention and Tobacco Control Act; Regulations on the Sale and Distribution of Tobacco Products and Required Warning Statements for Tobacco Products. Final rule. Federal Register; 10 May 2016. Available online: https://www.federalregister.gov/articles/2016/05/10/2016–10685/deeming-tobacco-products-to-be-subject-to-the-federal-food-drug-and-cosmetic-act-as-amended-by-the (accessed on 22 May 2017).
- Berry, C.; Burton, S.; Howlett, E. Are cigarette smokers’, e-cigarette users’, and dual-users’ health risk beliefs and responses to advertising influenced by addiction warnings and product type? Nicotine Tob. Res. 2017, 4. [Google Scholar] [CrossRef] [PubMed]
- Lee, Y.O.; Shafer, P.R.; Eggers, M.E.; Kim, A.E.; Parvanta, S.A.; Nonnemaker, J.M. Effect of a voluntary e-cigarette warning label on risk perceptions. Tob. Regul. Sci. 2016, 2, 82–93. [Google Scholar] [CrossRef]
- Wackowski, O.A.; Hammond, D.; O’Connor, R.J.; Strasser, A.A.; Delnevo, C.D. Smokers’ and E-Cigarette Users’ Perceptions about E-Cigarette Warning Statements. Int. J. Environ. Res. Public Health 2016, 13, 655. [Google Scholar] [CrossRef] [PubMed]
- Mays, D.; Smith, C.; Johnson, A.C.; Tercyak, K.P.; Niaura, R.S. An experimental study of the effects of electronic cigarette warnings on young adult nonsmokers’ perceptions and behavioral intentions. Tob. Induc. Dis. 2016, 14, 17. [Google Scholar] [CrossRef] [PubMed]
- Wackowski, O.A.; O’Connor, R.J.; Strasser, A.A.; Hammond, D.; Villanti, A.C.; Delnevo, C.D. Smokers’ and e-cigarette users’ perceptions of modified risk warnings for e-cigarettes. Prev. Med. Rep. 2016, 4, 309–312. [Google Scholar] [CrossRef] [PubMed]
- U.S. Food and Drug Administration. Citizen Petition Denial Response from FDA CTP to R.J. Reynolds Tobacco Company. Available online: https://www.regulations.gov/document?D=FDA-2011-P-0573-0059 (accessed on 31 May 2017).
- U.S. Food and Drug Administration. Response Letter to Swedish Match. Available online: http://www.fda.gov/TobaccoProducts/Labeling/MarketingandAdvertising/ucm522422.htm (accessed on 31 May 2017).
- Byrne, S.; Katz, S.J.; Mathios, A.; Niederdeppe, J. Do the ends justify the means? A test of alternatives to the FDA proposed cigarette warning labels. Health Commun. 2015, 30, 680–693. [Google Scholar] [CrossRef] [PubMed]
- Kraemer, J.D.; Baig, S.A. Analysis of legal and scientific issues in court challenges to graphic tobacco warnings. Am. J. Prev. Med. 2013, 45, 334–342. [Google Scholar] [CrossRef] [PubMed]
- U.S. Food and Drug Administration. Premarket Tobacco Product Applications for Electronic Nicotine Delivery Systems Guidance for Industry. Draft Guidance. Available online: https://www.fda.gov/downloads/tobaccoproducts/labeling/rulesregulationsguidance/ucm499352.pdf (accessed on 31 May 2017).
- Campaign for Tobacco Free Kids. 8 Health Groups File Suit to Force FDA to Require Graphic Cigarette Warnings as Mandated by Law. Available online: http://www.tobaccofreekids.org/press_releases/post/2016_10_04_fda (accessed on 31 May 2017).
- Lazard, A.J.; Schmidt, A.; Vu, H.; Byron, M.J.; Peters, E.; Boynton, M.H.; Brewer, N.T. Icons for health effects of cigarette smoke: A test of semiotic type. J. Behav. Med. 2017. [Google Scholar] [CrossRef]
- Thrasher, J.F.; Swayampakala, K.; Cummings, K.M.; Hammond, D.; Anshari, D.; Krugman, D.M.; Hardin, J.W. Cigarette package inserts can promote efficacy beliefs and sustained smoking cessation attempts: A longitudinal assessment of an innovative policy in Canada. Prev. Med. 2016, 88, 59–65. [Google Scholar] [CrossRef] [PubMed]
- Wackowski, O.A.; Delnevo, C.D. Smokers’ attitudes and support for e-cigarette policies and regulation in the USA. Tob. Control 2015, 24, 543–546. [Google Scholar] [CrossRef] [PubMed]
- Wackowski, O.A.; Manderski, M.T.; Delnevo, C.D. Smokers’ sources of e-cigarette awareness and risk information. Prev. Med. Rep. 2015, 2, 906–910. [Google Scholar] [CrossRef] [PubMed]
- Campaign for Tobacco Free Kids. International Issues—Warning Labels. Available online: http://global.tobaccofreekids.org/en/solutions/international_issues/warning_labels/ (accessed on 31 May 2017).
- Majeed, B.A.; Weaver, S.R.; Gregory, K.R.; Whitney, C.F.; Slovic, P.; Pechacek, T.F.; Eriksen, M.P. Changing perceptions of harm of e-cigarettes among U.S. adults, 2012–2015. Am. J. Prev. Med. 2017, 52, 331–338. [Google Scholar] [CrossRef] [PubMed]
© 2017 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Wackowski, O.A.; Hammond, D.; O’Connor, R.J.; Strasser, A.A.; Delnevo, C.D. Considerations and Future Research Directions for E-Cigarette Warnings—Findings from Expert Interviews. Int. J. Environ. Res. Public Health 2017, 14, 781. https://doi.org/10.3390/ijerph14070781
Wackowski OA, Hammond D, O’Connor RJ, Strasser AA, Delnevo CD. Considerations and Future Research Directions for E-Cigarette Warnings—Findings from Expert Interviews. International Journal of Environmental Research and Public Health. 2017; 14(7):781. https://doi.org/10.3390/ijerph14070781
Chicago/Turabian StyleWackowski, Olivia A., David Hammond, Richard J. O’Connor, Andrew A. Strasser, and Cristine D. Delnevo. 2017. "Considerations and Future Research Directions for E-Cigarette Warnings—Findings from Expert Interviews" International Journal of Environmental Research and Public Health 14, no. 7: 781. https://doi.org/10.3390/ijerph14070781