PURPOSE Assess the prevalence and correlates of e-cigarette perceptions and trial among adolescents in Mexico, where e-cigarettes are banned. METHODS Cross-sectional data were collected in 2015 from a representative sample of middle school students (n=10,146). Prevalence of e-cigarette awareness, relative harm, and trial were estimated, adjusting for sampling weights and school-level clustering. Multilevel logistic regression models adjusted for school-level clustering to assess correlates of e-cigarette awareness and trial. Finally, students who had tried only e-cigarettes were compared with students who had tried: 1) conventional cigarettes only; 2) both e-cigarettes and conventional cigarettes (dual triers); 3) neither cigarette type (never triers). RESULTS 51% of students had heard about e-cigarettes, 19% believed e-cigarettes were less harmful than conventional cigarettes, and 10% had tried them. Independent correlates of e-cigarette awareness and trial included established risk factors for smoking, as well as technophilia (i.e., use of more media technologies) and greater Internet tobacco advertising exposure. Exclusive e-cigarette triers (4%) had significantly higher technophilia, bedroom Internet access, and Internet tobacco advertising exposure compared to conventional cigarette triers (19%) and never triers (71%), but not compared to dual triers (6%), even though dual triers had significantly stronger conventional cigarette risk factors. CONCLUSIONS This study suggests that adolescent e-cigarette awareness and use is high in Mexico, in spite of its e-cigarette ban. A significant number of medium-risk youth have tried e-cigarettes only, suggesting that e-cigarettes could lead to more intensive substance use. Strategies to reduce e-cigarette use should consider reducing exposures to Internet marketing.

Objective This study aimed to determine the most effective content of pictorial health warning labels (HWLs) and whether educational attainment moderates these effects. Methods Field experiments were conducted with 529 adult smokers and 530 young adults (258 nonsmokers; 271 smokers), wherein participants reported responses to different HWLs printed on cigarette packages. One experiment involved manipulating textual form (testimonial narrative vs didactic) and the other involved manipulating imagery type (diseased organs vs human suffering). Results Tests of mean ratings and rankings indicated that HWLs with didactic textual forms had equivalent or significantly higher credibility, relevance, and impact than HWLs with testimonial forms. Results from mixed-effects models confirmed these results. However, responses differed by participant educational attainment: didactic forms were consistently rated higher than testimonials among participants with higher education, whereas the difference between didactic and testimonial narrative forms was weaker or not statistically significant among participants with lower education. In the second experiment, with textual content held constant, greater credibility, relevance and impact was found for graphic imagery of diseased organs than imagery of human suffering. Conclusions Pictorial HWLs with didactic textual forms appear to work better than with testimonial narratives. Future research should determine which pictorial HWL content has the greatest real-world impact among consumers from disadvantaged groups, including assessment of how HWL content should change to maintain its impact as tobacco control environments strengthen and consumer awareness of smoking-related risks increases.

Comprehensive smoke-free legislation in Mexico City has been relatively successful, with changes in perceptions and behavior consistent with those revealed by studies conducted in high-income countries. Normative changes may prime populations for additional tobacco control interventions.

Social marketing campaigns can reinforce knowledge and attitudes that favor smoke-free laws, thereby helping to establish smoke-free norms.

Objective To determine whether exposure to smoking imagery in films predicts smoking onset among never-smoking Mexican adolescents. Methods The analytic sample was comprised of 11- to 14-year old secondary school students who reported never having tried smoking at baseline, 83% (1741/2093) of whom were successfully followed up after one year. Exposure to 42 popular films that contained smoking was assessed at baseline, whereas smoking behavior and risk factors were assessed at baseline and follow up. Logistic regression was used to estimate bivariate and adjusted relative risks of trying smoking and current smoking at follow up. Results At follow up, 36% reported having tried smoking and 8% reported having smoked in the previous month. Students who were successfully followed up were exposed to an average of 43.8 minutes of smoking in the films they reported viewing at baseline. Adjusted relative risks (ARRs) indicated that students in the two highest levels of exposure to film smoking were more than twice as likely to have smoked in the previous 30 days at follow up (ARR3v1=2.44, 95%CI 1.31, 4.55; ARR4v1=2.23, 95% CI 1.19, 4.17). The adjusted relative risk of having tried smoking by follow up reached statistical significance only when comparing the 3rd highest to the lowest exposure group (ARR3v1=1.54, 95%CI 1.01, 2.64). Having a parent or best friend who smoked at baseline were the only other variables that independently predicted both outcomes. Conclusions Exposure to movie smoking is a risk factor for smoking onset among Mexican youth.