Pack Modifications Influence Perceptions of Menthol E-cigarettes Amy M. Cohn, PhD Amanda L. Johnson, MHS Haneen Abudayyeh, MPH Bonnie King, MHS Jess Wilhelm, PhD Objectives: Tobacco package colors and descriptors influence attitudes and intentions to use. This study examined the impact of flavor, color, and descriptors on electronic cigarette (e-cigarette) packages young adults’ perceptions of e-cigarettes. Methods: We recruited 2872 US participants ages 18-24 from Amazon Mechanical Turk (2018-2019) and randomized them to view one of 7 e-cigarette package images that varied by flavor (menthol vs tobacco), color (green or brown vs black and white), and descriptor (present vs absent). Models examined main and interactive effects of flavor, color, and descriptor on perceptions of appeal, harm, and addictiveness, and the moderating effects of product appeal. Results: Menthol e-cigarette packages were rated as more “attention grabbing,” “appetizing,” and “fun to use.” Perceptions of harm and addictiveness did not vary across package conditions. Interactions of menthol pack conditions with appeal emerged. Specifically, participants exposed to the green package with the menthol descriptor reported low e-cigarette harm perceptions across all levels of “attention grabbing” and “discour- ages use,” while those exposed to the green package without the menthol descriptor or the brown package with the tobacco descriptor reported lower harm perceptions as ratings of prod- uct appeal increased. Conclusions: Colors and descriptors on e-cigarette packaging influence product appeal and harm perceptions. Key words: flavored tobacco; menthol; e-cigarettes; young adults; perceived harm; perceived addictiveness; appeal; packaging; marketing; tobacco companies Tob Regul Sci.™ 2021;7(2):87-102 DOI: doi.org/10.18001/TRS.7.2.1 urveillance data show that the prevalence of bacco smoke or vapor, making it easier for new us- current e-cigarette use has increased signifi- ers to initiate tobacco use. Flavors also have been cantly among young adults ages 18-24,1 and posited to enhance the appeal and attractiveness Sflavors are a prominent reason for use.2-6 E-ciga- of tobacco products because of their high reward rettes are electronic or battery-powered devices that value and history of associations with candy and heat liquid, usually containing nicotine, into aero- other food items.7 Experimentation with flavored solized content that can be inhaled. Findings from tobacco products has been linked to progression the PATH Study (2014-2015) show that 66.7% to regular tobacco use and nicotine dependence in of past 30-day young adult e-cigarette users report youth and young adults.8-13 use of a flavored e-cigarette.5 Flavors have been The US Food and Drug Administration (FDA) hypothesized to mask the harshness of inhaled to- issued regulatory action in January 2020 ban- Amy M. Cohn, Associate Professor, Department of Pediatrics, TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States. Amanda L. Johnson, Senior Research Biostatistician, TSET Health Promo- tion Research Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States. Haneen Abudayyeh, Researcher, Public Health Center for Substance Use Research, Battelle Memorial Institute, Baltimore, MD, United States. Bonnie King, Research Project Manager, Pub- lic Health Center for Substance Use Research, Battelle Memorial Institute, Baltimore, MD, United States. Jess Wilhelm, Principal Research Scientist and Biostatistician, Public Health Center for Substance Use Research, Battelle Memorial Institute, Baltimore, MD, United States. Correspondence Dr Cohn; [email protected] Tob Regul Sci.™ 2021;7(2):87-102 87 Pack Modifications Influence Perceptions of Menthol E-cigarettes ning cartridge-based flavored e-cigarettes, includ- tally examined whether modifying different aspects ing fruit and mint flavors. However, menthol and of e-cigarette packaging (flavor, descriptor, color) tobacco flavored e-cigarettes, both cartridge and influences perceptions of appeal, harm, and ad- non-cartridge-based, remain available to consum- dictiveness, using a large sample of over 2800 US ers. This is concerning because menthol is one of young adults. The first objective examined the the top 3 most common e-cigarette flavors used by main and interactive effects of flavor type (men- young adults.5 Published data suggest that sales of thol vs tobacco), package color (color vs black and menthol e-cigarettes could increase following the white/B&W), and flavor descriptor (present or ab- removal of fruit and candy-flavored e-cigarettes sent) on perceptions of e-cigarette appeal, harm, from the market.14 Furthermore, many new dispos- and addictiveness. The second objective examined able e-cigarette devices have entered the market to the associations between ratings of appeal with per- provide flavors that have been banned in cartridge- ceptions of e-cigarette harm and addictiveness, and based e-cigarettes. the moderating effect of appeal ratings on the as- Packaging and marketing also influence the al- sociations of menthol packages with perceptions of lure and perceived attractiveness of flavored to- e-cigarette harm and addictiveness. We specifically bacco products.7,15,16 Tobacco companies have long recruited a general sample of young adults rather manipulated the characteristics of tobacco prod- than a selected group defined by their tobacco use ucts through packaging and marketing, targeted to status (eg, susceptible e-cigarette users, never e-cig- specific vulnerable and at-risk sub-groups, includ- arette users) so that findings could be generalizable ing young adult smokers and non-smokers who are to a larger audience of young adults, who may be susceptible to use.17-20 Tobacco industry documents consumers of tobacco products in the future. highlight that youth and young adult smokers are especially curious about trying flavored products.16 METHODS Younger individuals who have never used a tobacco Participants and Procedure product are familiar with candy and fruit flavors Participants were recruited via Amazon Mechani- and less likely to have experience with “tobacco” as cal Turk (AMT) between 2018 and 2019. Eligible a flavor. Thus, images and descriptors on tobacco individuals were ages of 18 and 24, resided in the product packaging that mimic or portray these ap- US, and reported a 95% approval rating on AMT. pealing flavors (eg, cherry, chocolate) may increase AMT is a crowdsourcing platform that allows for desire to use a tobacco product. Young people also rapid and cost-effective study recruitment.23,24 may be more likely to associate the characteriz- AMT workers are compensated for completing ing flavor of “tobacco” with greater perceptions of small, discrete tasks, called “Human Intelligence harm and addiction, given the widespread knowl- Tasks,” or HITs. Workers search the AMT website edge about the deleterious health effects of ciga- 21 for a HIT, which can be pre-viewed before starting rette smoking. This may make tobacco-flavored a task.25,26 This study was completed online. products less appealing. After completing a brief eligibility screen and Certain descriptors on tobacco packaging and providing consent, 2879 participants were ran- advertisements, such as “light,” “mild,” and “low,” domized to view one of 7 different images of an e- have been found to mislead consumers into think- cigarette package in which flavor type (menthol vs ing that the product is less harmful than other to- 22 tobacco), presence or absence of a flavor descriptor, bacco products. As a result, several descriptors and color were manipulated. One of the conditions were banned under the 2009 Family Smoking was a “control condition” that had no flavor de- Prevention and Tobacco Control Act (FSPTCA). scriptor and black and white color on the package. However, flavor descriptors on cigarettes and other Twenty participants completed the survey in less tobacco products have not been banned. Few data than 120 seconds and were removed from all analy- exist on the ways in which young adult appeal for ses in an effort to control for inattentiveness to the flavored e-cigarettes is influenced by packaging, task, leaving a total sample of 2859 participants in a product characteristic that can be regulated by the analysis. FDA. To address this gap, this study experimen- The 7 package conditions are described as follows 88 Cohn et al Figure 1 Experimental Stimuli by Study Condition No Descriptor “Classic Tobacco” “Magnificent Menthol” Black and Package C White Package A Package F (B&W) Brown Color Package G Package E Green Color Package D Package B Tob Regul Sci.™ 2021;7(2):87-102 DOI: doi.org/10.18001/TRS.7.2.1 89 Pack Modifications Influence Perceptions of Menthol E-cigarettes (Figure 1): (1) control condition (black and white, ever (not current), and past 30-day cigarette and no descriptor); (2) green e-cigarette package with e-cigarette use, as well as ever and past 30-day use menthol descriptor (“Magnificent Menthol”); (3) of menthol flavored e-cigarettes. black and white (B&W) e-cigarette package with Perceived absolute addictiveness. After viewing menthol descriptor; (4) green e-cigarette package the randomized package image, participants were without menthol descriptor; (5) brown e-cigarette asked: “How addictive do you think e-cigarettes are package with tobacco descriptor (“Classic Tobac- to health?” (1 = not at all addictive to 5 = extremely co”); (6) B&W e-cigarette package with tobacco addictive). descriptor; and (7) brown e-cigarette package with- Perceived absolute harmfulness. Participants out tobacco descriptor. We used the Blu e-cigarette were asked: “How harmful do you think e-ciga- brand given its high level of familiarity and pop- rettes are to health?” (1 = not at all harmful to 5= ularity at the time the study was conceptualized 28 extremely harmful). and funded (2017). Menthol was selected given Package appeal. After viewing the randomized its high policy relevance and popularity in young 29-37 package image, participants were asked about 8 dif- adults.