Objective To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings. Data sources We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles. Study selection We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33 613) met criteria. Data extraction and synthesis Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures. Results Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes. Conclusions The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.

Objective We sought to systematically review the literature on electronic nicotine delivery systems (ENDS, also called electronic cigarettes) awareness, use, reactions and beliefs. Data sources We searched five databases for articles published between 2006 and 1 July 2013 that contained variations of the phrases ‘electronic cigarette’, ‘e-cigarette’ and ‘electronic nicotine delivery’. Study selection Of the 244 abstracts identified, we excluded articles not published in English, articles unrelated to ENDS, dissertation abstracts and articles without original data on prespecified outcomes. Data extraction Two reviewers coded each article for ENDS awareness, use, reactions and beliefs. Data synthesis 49 studies met inclusion criteria. ENDS awareness increased from 16% to 58% from 2009 to 2011, and use increased from 1% to 6%. The majority of users were current or former smokers. Many users found ENDS satisfying, and some engaged in dual use of ENDS and other tobacco. No longitudinal studies examined whether ENDS serve as ‘gateways’ to future tobacco use. Common reasons for using ENDS were quitting smoking and using a product that is healthier than cigarettes. Self-reported survey data and prospective trials suggest that ENDS might help cigarette smokers quit, but no randomised controlled trials with probability samples compared ENDS with other cessation tools. Some individuals used ENDS to avoid smoking restrictions. Conclusions ENDS use is expanding rapidly despite experts’ concerns about safety, dual use and possible ‘gateway’ effects. More research is needed on effective public health messages, perceived health risks, validity of self-reports of smoking cessation and the use of different kinds of ENDS.

Abstract:The aim of our study was to explore reasons for starting and then stopping electronic cigarette (e-cigarette) use. Among a national sample of 3878 U.S. adults who reported ever trying e-cigarettes, the most common reasons for trying were curiosity (53%); because a friend or family member used, gave, or offered e-cigarettes (34%); and quitting or reducing smoking (30%). Nearly two-thirds (65%) of people who started using e-cigarettes later stopped using them. Discontinuation was more common among those whose main reason for trying was not goal-oriented (e.g., curiosity) than goal-oriented (e.g., quitting smoking) (81% vs. 45%, p < 0.001). The most common reasons for stopping e-cigarette use were that respondents were just experimenting (49%), using e-cigarettes did not feel like smoking cigarettes (15%), and users did not like the taste (14%). Our results suggest there are two categories of e-cigarette users: those who try for goal-oriented reasons and typically continue using and those who try for non-goal-oriented reasons and then typically stop using. Research should distinguish e-cigarette experimenters from motivated users whose decisions to discontinue relate to the utility or experience of use. Depending on whether e-cigarettes prove to be effective smoking cessation tools or OPEN ACCESSInt. J. Environ. Res. Public Health 2014, 11 10346 whether they deter cessation, public health programs may need distinct strategies to reach and influence different types of users.

Background More U.S. adolescents use e-cigarettes than smoke cigarettes. Research suggests flavored e-cigarettes appeal to youth, but little is known about perceptions of and reasons for attraction to specific flavors. Methods A national sample of adolescents (n=1,125) ages 13-17 participated in a phone survey from November 2014-June 2015. We randomly assigned adolescents to respond to survey items about 1 of 5 e-cigarette flavors (tobacco, alcohol, menthol, candy, or fruit) and used regression analysis to examine the impact of flavor on interest in trying e-cigarettes and harm beliefs. Results Adolescents were more likely to report interest in trying an e-cigarette offered by a friend if it were flavored like menthol (OR=4.00, 95% CI 1.46-10.97), candy (OR=4.53, 95% CI 1.67-12.31), or fruit (OR=6.49, 95% CI 2.48-17.01) compared to tobacco. Adolescents believed that fruit-flavored e-cigarettes were less harmful to health than tobacco-flavored e-cigarettes (p<.05). Perceived harm mediated the relationship between some flavors and interest in trying e-cigarettes. A minority believed that e-cigarettes did not have nicotine (14.6%) or did not know whether they had nicotine (3.6%); these beliefs did not vary by flavor. Discussion Candy, fruit, and menthol-flavored e-cigarettes appeal to youth more than tobacco or alcohol-flavored, but the appeal is only partially explained by beliefs about reduced harm. Given adolescents’ interest in trying e-cigarettes with certain flavors, policymakers should consider restricting advertisements promoting flavored products in channels that reach large numbers of young people. Future research should examine other reasons for the appeal of individual flavors, such as novelty and perceived prestige.

Purpose Electronic cigarettes (e-cigarettes) are a new type of device that delivers vaporized nicotine without the tobacco combustion of regular cigarettes. We sought to understand awareness of and willingness to try e-cigarettes among adolescent males, a group that is at risk for smoking initiation and may use e-cigarettes as a “gateway” to smoking. Methods A national sample of 11–19-year-old males (n =228) completed an online survey in November 2011. We recruited participants through their parents, who were members of a panel of U.S. households constructed using random-digit dialing and addressed-based sampling. Results Only two participants (< 1%) had previously tried e-cigarettes. Among those who had not tried e-cigarettes, most (67%) had heard of them. Awareness was higher among older and non- Hispanic adolescents. Nearly 1 in 5 (18%) participants were willing to try either a plain or flavored e-cigarette, but willingness to try plain versus flavored varieties did not differ. Smokers were more willing to try any e-cigarette than nonsmokers (74% vs. 13%; OR 10.25, 95% CI 2.88, 36.46). Nonsmokers who had more negative beliefs about the typical smoker were less willing to try e-cigarettes (OR .58, 95% CI .43, .79). Conclusions Most adolescent males were aware of e-cigarettes, and a substantial minority were willing to try them. Given that even experimentation with e-cigarettes could lead to nicotine dependence and subsequent use of other tobacco products, regulatory and behavioral interventions are needed to prevent “gateway” use by adolescent nonsmokers. Campaigns promoting negative images of smokers or FDA bans on sales to youth may help deter use.