E-cigarette Marketing Regulations and Youth Vaping: Cross-Sectional Surveys, 2017–2019 David Hammond, PhD, Jessica L. Reid, MSc, Robin Burkhalter, MMath, Vicki L. Rynard, MSc BACKGROUND: Increased electronic cigarette (e-cigarette) use among young people is often abstract attributed to industry marketing practices; however, the effectiveness of regulations that limit e-cigarette advertising and promotions has yet to be examined. New federal legislation that liberalized the Canadian e-cigarette market in May 2018, along with differences in provincial regulations, provides an opportunity to examine the impact of regulatory restrictions on e-cigarette marketing. METHODS: Repeat cross-sectional surveys of 12 004 16- to 19-year-olds in Canada, completed online in 2017, 2018, and 2019. Logistic regression models were used to examine differences over time in exposure to e-cigarette marketing and e-cigarette use, including between provinces with differing strengths of marketing restrictions. RESULTS: The percentage of youth surveyed who reported noticing e-cigarette promotions often or very often approximately doubled between 2017 and 2019 (13.6% vs 26.0%; adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.97–2.56). Overall exposure to marketing was generally more prevalent in provinces with fewer regulatory restrictions. Respondents who reported noticing marketing often or very often were more likely to report vaping in the past 30 days (AOR = 1.41, 95% CI = 1.23–1.62), past week (AOR = 1.44, 95% CI = 1.22–1.70), and $20 days in the past month (AOR = 1.42, 95% CI = 1.11–1.81, P = .005). Provinces with low restrictions on marketing had higher prevalence of vaping in the past 30 days (AOR = 1.50, 95% CI = 1.25–1.80, P , .001), and in the past week (AOR = 1.65, 95% CI = 1.33–2.05, P , .001). CONCLUSIONS: Exposure to marketing and the prevalence of vaping increased among Canadian youth after the liberalization of the e-cigarette market in 2018. Comprehensive provincial restrictions on e-cigarette marketing were associated with lower levels of exposure to marketing and lower prevalence of e-cigarette use. WHAT’S KNOWN ON THIS SUBJECT: Although increased vaping among youth School of Public Health and Health Systems, University of Waterloo, Waterloo, Ontario, Canada is often attributed to industry marketing, the effectiveness of regulations Dr Hammond conceptualized and designed the study and drafted sections of the initial manuscript; that limit electronic cigarette (e-cigarette) marketing has yet to be examined. In Canada, federal legislation liberalized the e-cigarette market in Ms Reid helped design the data collection instruments, coordinated and supervised data collection, 2018, and provincial regulations differ in strength. and drafted sections of the initial manuscript; Ms Burkhalter led the data analysis and drafted sections of the initial manuscript; Ms Rynard carried out data management and weighting and WHAT THIS STUDY ADDS: Exposure to marketing and the prevalence of assisted with analyses; and all authors reviewed and revised the manuscript and approved the final vaping increased among Canadian youth after the liberalization of the e-cigarette market. Comprehensive provincial restrictions on e-cigarette manuscript as submitted and agree to be accountable for all aspects of the work. marketing were associated with lower levels of exposure to marketing and lower prevalence of e-cigarette use. To cite: Hammond D, Reid JL, Burkhalter R, et al. E-cigarette Marketing Regulations and Youth Vaping: Cross-Sectional Surveys, 2017–2019. Pediatrics. 2020; 146(1):e20194020 Downloaded from www.aappublications.org/news by guest on September 24, 2021 PEDIATRICS Volume 146, number 1, July 2020:e20194020 ARTICLE Electronic cigarette (e-cigarette) use tobacco marketing increases smoking among young people. In 3 studies that among North American youth has behavior among young people by included comparison of exposure increased considerably over the past promoting positive attitudes and across countries with different 2 years.1–3 According to recent beliefs toward tobacco use while restrictions, the conclusions were that estimates, approximately one-quarter reducing perceptions of risk.22,23 marketing exposure was higher of Canadian youth have used among youth and adults in the United Recent regulatory changes had e-cigarettes in the past 30 days, with States and Canada compared with a substantial impact on the increasing prevalence of daily or near England and Australia, countries with e-cigarette market in Canada. Before daily use, similar to trends in the greater restrictions.12,26,27 implementation of the Tobacco and United States.2,3 Increased use of Vaping Products Act (TVPA) in May The implementation of the TVPA in e-cigarettes among young people is 2018, e-cigarettes containing nicotine 2018 and the differing regulatory frequently attributed to industry could not be sold or advertised in restrictions across Canadian marketing practices. Leading Canada without premarket provinces has created the conditions e-cigarette brands such as JUUL are approval.24 Although e-cigarettes for a “natural experiment” to test the currently being investigated by the US were still widely available in vape impact of e-cigarette marketing: Food and Drug Administration for shops and online, there was little although marketing practices targeting young people through social coordinated advertising or increased in all provinces in 2018, we media with lifestyle-oriented – promotion, and the market was hypothesize that they increased to imagery.4 7 Few federal restrictions composed of smaller brands.25 After a greater extent in provinces with are placed on e-cigarette marketing in the TVPA, e-cigarettes containing fewer restrictions. Accordingly, in our the US, except that marketing nicotine became legally available for current study, we had 3 primary materials cannot include sale, which increased retail access for objectives: (1) to examine changes in unauthorized claims of reduced harm major international brands, such as exposure to e-cigarette marketing or cessation.8 One of the leading JUUL and Vype. The TVPA also before and after implementation of Canadian brands, Vype, has also been permitted marketing, including the TVPA, (2) to examine whether the focus of disciplinary action from advertisements in mass media exposure differed on the basis of the Health Canada over lifestyle channels, such as radio, television, strength of provincial marketing marketing in public areas,9 and and print, and at the point of sale, so restrictions, and (3) to test whether Health Canada has issued advisories long as the content of ads did not exposure to e-cigarette marketing to retailers regarding compliance appeal to youth or include “lifestyle” was associated with the prevalence of with federal regulations.10 advertising or personal testimonials. vaping. Several provinces implemented Estimates from population-based supplementary restrictions on studies indicate widespread exposure METHODS e-cigarette advertising, including to e-cigarette marketing among Quebec and Manitoba, which youth.11 In 2017, approximately Data Source implemented comprehensive three-quarters of Canadian youth Data are from waves 1 to 3 of the restrictions similar to tobacco reported exposure to e-cigarette International Tobacco Control Policy products, including a ban on retail marketing in the past 30 days, and in Evaluation Project (ITC) Youth displays and advertisements. Other the United States increasing exposure Tobacco and Vaping Survey, provinces, such as Alberta and over time is indicated.12,13 Greater conducted in Canada, England, and Saskatchewan, added few restrictions exposure to e-cigarette advertising the United States. Online surveys beyond the federal requirements. and promotions is associated with were conducted in July and August – Although Canada legalized increased likelihood of use,11,12,14 16 2017 (wave 1), August and recreational cannabis in October including in prospective cohort September 2018 (wave 2), and 2018, cannabis or studies, in which exposure to August and September 2019 (wave tetrahydrocannabinol (THC) vape oils advertising at baseline predicts 3). The same methods and were not permitted until 2020 and subsequent e-cigarette use.17,18 In recruitment protocols were used in are subject to more comprehensive experimental studies, exposure to all 3 countries. Respondents were restrictions than nicotine e-cigarettes, e-cigarette advertisements has recruited from the Nielsen Consumer similar to tobacco products in increased positive perceptions and Insights Global Panel, which Canada. interest in using e-cigarettes among maintains panels in Canada, England, young people, including among To date, there is little evidence on the and the United States, as well as their “never” users.19–21 These findings are impact of regulatory restrictions on partners’ panels. The Nielsen panel is consistent with the evidence that exposure to e-cigarette marketing recruited by using both probability Downloaded from www.aappublications.org/news by guest on September 24, 2021 2 HAMMOND et al and nonprobability sampling Committee (ORE#21847) and the permitted): television, radio, methods in each country. We King’s College London Psychiatry, billboards (restricted in Quebec, identified target sample sizes of 4500 Nursing, and Midwifery Research Manitoba, Prince Edward Island, Nova for each country at each wave, based Ethics Subcommittee. Scotia), and advertisements or on sample