Adolescents’ responses to the promotion and flavouring of e-cigarettes

It is well established that exposure to, and appreciation of, tobacco marketing is linked with youth smoking and smoking susceptibility (Lovato et al. 2011; National Cancer Institute 2008). Similarly, evidence shows that tobacco flavourings appeal to young and novice smokers, particularly fruit, candy, and alcohol flavours (Carpenter et al. 2005; Wayne and Connolly 2002). In recent years, electronic cigarettes (e-cigarettes) have been marketed as an alternative to smoking. These devices do not contain tobacco, and national regulatory bodies in some countries, including the UK, have made it clear that they are less harmful than tobacco (MHRA 2013; NICE 2013). However, some e-cigarettes closely resemble cigarettes and the marketing strategies used to promote them have been similar to those used for tobacco (de Andrade et al. 2013). Research exploring how young people respond to e-cigarette marketing and flavours has been lacking.

A review of the literature exploring the impact of e-cigarettes on children found that, whilst there is evidence of increased youth exposure to advertisements (Duke et al. 2014), the effects of e-cigarette marketing and the availability of flavoured e-liquids on youth use are unknown (Durmowicz 2014). There is some evidence that adult exposure to e-cigarette advertising can increase interest in trying the product (Pepper et al. 2014), affect perceptions of product-related harms (Tan et al. 2015), and is associated with use (Harrington et al. 2014). Observing vaping in e-cigarette advertisements is also linked with an increase in daily adult smokers’ urge to smoke (Maloney and Cappella 2015). Furthermore, positive appraisal of advertisements has been associated with intended use among college students (Trumbo and Kim 2015).

Advertising is of course just one type of promotion. E-cigarette promotion takes place in multiple channels, including those previously used for traditional cigarettes and for other consumer products, such as product and packaging design, point-of-sale, billboards, radio and TV advertising, sponsorship, traditional print media, and celebrity endorsements, plus an array of online and social media options (de Andrade et al. 2013). This has been supported by increasing promotional expenditures (Kornfield et al. 2014) and resulted in concern about possible targeting of young people. Content analyses of e-cigarette promotions have found that it often conveys messages of sociability and sexuality (Richardson et al. 2014), which may tap into adolescent concerns about group and gender identity (Amos and Bostock 2007). It is clear, therefore, that research exploring the effects, if any, of e-cigarette promotion on children is important.

In addition to the potential influence e-cigarette promotions may have on youth, there is a need to understand the role that aspects of product design, such as flavourings, have on how children perceive e-cigarettes, particularly as it has been suggested that e-cigarette flavours could appeal to young non-smokers (Giovenco et al. 2014; Hughes et al. 2015). What is known is that there are myriad e-cigarette flavours available. An analysis of brands advertised and sold on the internet found that in a 17-month period, between 2012 and 2014, 242 new flavours were introduced each month. By January 2014, the total number of flavour offerings exceeded 7700 (Zhu et al. 2014).

This growth in flavours may not be surprising, as products have diversified and adult smokers who use e-cigarettes express preferences for a range of flavours. The most recent Eurobarometer survey found that amongst current adult users of e-cigarettes, flavour was the most important factor in their choice of product (39 % of respondents) followed by price (38 %) and nicotine content (27 %) (European Commission 2015). Smokers who successfully quit with e-cigarettes cite alternative flavours (other than tobacco) as important in breaking the link with smoking (Farsalinos et al. 2013). Smoking significantly increases the risk of impaired olfactory function (Vennemann et al. 2008). Smokers who quit report regaining their sense of taste and smell as one of the benefits of cessation, allowing greater appreciation of flavours. A choice of flavours may play a valuable role in e-cigarette product appeal to smokers who are trying to quit.

However, much as with promotion, few studies have explored young people’s perceptions of e-cigarette flavours. While two studies found little interest in flavoured e-cigarettes among teenagers (Pepper et al. 2013; Shiffman et al. 2015), another suggested that flavours encourage e-cigarette experimentation (Kong et al. 2014). A further two studies highlighted adolescent preference for sweet flavours (Krishnan-Sarin et al. 2015; McNeill et al. 2015). For example, a UK survey found that just over 50 % of 11- to 18-year-old ever-users reported that their last e-cigarette had contained a fruit flavour, but less than 10 % said it had contained a tobacco flavour (McNeill et al. 2015).

This study helps fill gaps in the literature. It examines awareness and use of e-cigarettes among UK adolescents, as well as awareness of e-cigarette promotion, branding, and flavours. It also investigates whether e-cigarette flavours affect perceptions of product harm and user image.

This UK study adds to the literature on e-cigarettes in three ways: it confirms existing data on usage (Bauld et al. 2015); it provides new data on response to promotion and branding; and it gives a first look at reactions to different flavourings. Prevalence of e-cigarette use, at 12 %, is consistent with other studies conducted in the UK in the same 12-month period, including national surveys in Scotland (ISD Scotland 2014) and Wales (Moore et al. 2015). As with these other surveys, only a small proportion of never smokers reported e-cigarette use. No regular use among never smokers was identified here or in the Scotland study, and only a tiny proportion (0.3 %) was reported in the Wales study.

The vast majority of our sample had heard of e-cigarettes and over two-thirds knew that they came in different flavours. There was high awareness of e-cigarette promotion, with most participants aware of at least one type of promotion. However, awareness of e-cigarette branding—a key promotional driver of consumption—was very low. Unlike in the US, where consolidation of the market has created a small number of brand leaders (Giovenco et al. 2014), the UK market remains fragmented. However, US-style rationalisation is expected following tobacco company involvement in the market (Hegarty 2015).

Participants were asked about the absolute harm of e-cigarettes, rather than harm relative to tobacco cigarettes. E-cigarettes were generally seen as harmful and not intended for young people, although these perceptions were influenced by flavour descriptors. For instance, tobacco-flavouring increased harm perceptions, suggesting that awareness of the hazards of tobacco is having an effect. In contrast, fruit and sweet flavours decreased perceptions of harm.

This is the first study to explore adolescents’ awareness of different types of e-cigarette promotion and the influence of flavour descriptors on beliefs of product harm and user image. It benefits from a national sample of UK adolescents. There are a number of study limitations. The cross-sectional nature of the study does not enable causal associations to be explored between awareness of marketing and product-related beliefs or e-cigarette use. While the survey explored awareness of nine different types of e-cigarette promotions, it did not cover all types of promotion. The study also focused on four examples of flavour descriptors: tobacco, cherry, candy floss and coffee. The findings may not apply to other flavours in the same category, for example, an alternative fruit or sweet flavour may not be perceived to be less harmful than a tobacco flavoured e-cigarette.

While the findings suggest that non-smokers are not currently being drawn into using e-cigarettes, there is a need to monitor the situation over time as both the market and regulatory environment develops and changes. Pending regulation in many jurisdictions will significantly restrict e-cigarette marketing. In areas with fewer restrictions, e-cigarette manufacturers may utilise marketing avenues such as free gifts and trials, brand stretching, direct promotional mail, competitions, novel and innovative packaging and product design, and future developments in digital channels to communicate with potential consumers. Further research is needed to monitor e-cigarette marketing strategies, along with adolescents’ exposure to, and involvement with them, and any associated influence on e-cigarette trial and regular use.

The influence of perceptions of product harm and flavours should also be further examined. For adult smokers, flavours can play a useful role in quitting by increasing the appeal of e-cigarettes and helping migration away from tobacco (Farsalinos et al. 2013). In this survey, young people perceived that a never smoker of their age may be more likely to try a candy floss-flavoured e-cigarette than an adult smoker. This highlights the fact that cues like flavour descriptors not only suggest product attributes such as harm, but also other constructs such as user image. While previous studies have suggested little interest among teenagers in trying flavoured e-cigarettes (Shiffman et al. 2015; Pepper et al. 2013), whether user image perceptions makes certain flavours of e-cigarettes attractive to young never smokers, or motivates experimentation, requires further exploration. Marketing literature shows that user image of a product provides a stereotypical view of the generalised user and can shape consumer perceptions and peer acceptance of a product. There is evidence that a cognitive match between an individual’s self-concept and the user image of a product (self-image congruence) (Sirgy 1982) can influence purchase and consumption (Hosany and Martn 2012).

Young people would benefit from clear and consistent information about e-cigarette products and product harm, including their relative harm compared with tobacco cigarettes. E-cigarette marketing is reaching a broad audience and different flavour categories may blur the message about the intended user. These concerns help explain policymakers’ plans to place restrictions on e-cigarette marketing. E-cigarette advertising is permitted in the UK under the Committees for Advertising Practise (CAP) rules which state that advertisements must not encourage non-smokers and non-nicotine users to use e-cigarettes and must not appeal to anyone under 18 (Committees of Advertising Practice 2014). In 2016, however, the European Union’s Tobacco Products Directive (TPD) will override EU member states’ current domestic arrangements and impose a ban on e-cigarette advertising, promotion and sponsorship, similar to current restrictions for tobacco products (European Parliament and the Council of the European Union 2014). Furthermore, the TPD allows member states to regulate the availability of flavours. Wills et al. (2015) have noted that attention should be given to e-cigarette marketing and the perceived attractiveness of e-cigarettes because of flavourings. This study reinforces their point.