week-2 Resources reviews

Am J Health Behav.™ 2015;39(3):361-371 361

T here is an upsurge in tobacco industry ad- vertising to encourage cigarette smokers to use electronic cigarettes (e-cigarettes) in no-

smoking areas and as an aid to smoking cessation. E-cigarettes are devices that include a battery-pow- ered heating element designed to heat and aerosol- ize liquids containing varying levels of nicotine, fla- voring agents, a number of unknown components, and in some cases tobacco itself.1 Aerosolized nic- otine in e-cigarettes contains glycerine to mimic smoke of conventional cigarettes while supposedly delivering lower toxin levels than those found in a conventional cigarette.2-5 Vaporizers (or vape-pens) are similar to e-cigarettes, but typically contain a larger battery with variable heat settings to heat a refillable tank with a wick for liquid nicotine or a compartment for vaporizing THC oil or even can- nabis buds. Vaporizers are more expensive than e- cigarettes, and their higher heat levels can deliver a larger dose of nicotine vapor. The nicotine can be purchased in varying concentrations and flavors.

There is a dearth of information on the perceptions and use of e-cigarettes among older adults.

Prevalence and Impact of Smoking in Older Adults

Older smokers initiated smoking when it was ubiquitous and they were most impacted by indoor smoking bans. Disparities in tobacco use among adults continue to exist by race/ethnicity, educa- tion, income, and mental health status.6 In the last decade, smoking prevalence has declined in all age groups in the US except for older smokers. In fact, smoking prevalence for adults over 65 actually has increased. In 2011, smoking prevalence for 45- 64 year-olds was 19.5%, higher than the national average of 18%.7 These statistics reflect both the marginalization of older smokers by society and tobacco research funding,8 and the fact that older smokers are targeted by an aggressive tobacco in- dustry.9 Older smokers frequently face economic and social disadvantages; yet, they are often ig- nored in discussions of marginalized populations impacted by tobacco.10-13

Because older smokers underestimate both the risks of smoking and the benefits of cessation, they are the least likely to quit of any age group.13 Older adults have the greatest smoking related health burden.14 However, quitting smoking, at any age, decreases cardiovascular risk and provides sig- nificant health benefits and quitting by age 50 re- duces the risk of lung cancer by half.15 Yet, older adults (45-64 year-olds) are often unaware of these benefits.16 A primary reason for these mispercep-

Janine K. Cataldo, Associate Professor, University of Cali- fornia, San Francisco School of Nursing, San Francisco, CA. Anne Berit Petersen, Doctoral Candidate, University of Cali- fornia, San Francisco School of Nursing, San Francisco, CA. Mary Hunter, Doctoral Student, University of California, San Francisco School of Nursing, San Francisco, CA. Julie Wang, Postdoctoral Fellow, University of California, San Francisco, Center of Tobacco Control, Research, and Education, San Francisco, CA. Nicolas Sheon, University of California, San Francisco, Department of Medicine, San Francisco, CA. Correspondence Dr Cataldo; [email protected]

E-cigarette Marketing and Older Smokers: Road to Renormalization

Janine K. Cataldo, RN, PhD, FAAN; Anne Berit Petersen, RN, MS, MPH; Mary Hunter, MN; Julie Wang, MPH, PhD; Nicolas Sheon, PhD

Objectives: To describe older smokers’ perceptions of risks and use of e-cigarettes, and their responses to marketing and knowledge of, and opinions about, regula- tion of e-cigarettes. Methods: Eight 90-min- ute focus groups with 8 to 9 participants met in urban and suburban California to discuss topics related to cigarettes and al- ternative tobacco products. Results: Older adults are using e-cigarettes for cessation and as a way to circumvent no-smoking policies; they have false perceptions about

the effectiveness and safety of e-cigarettes. They perceive e-cigarette marketing as a way to renormalize smoking. Conclusions: To stem the current epidemic of nicotine addiction, the FDA must take immediate action because e-cigarette advertising pro- motes dual use and may contribute to the renormalization of smoking.

Key words: older smokers; e-cigarettes; marketing; perception; use

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tions is the tobacco industry’s aggressive targeting of older smokers8 in the marketing of both con- ventional and emerging tobacco products, such as e-cigarettes and vaporizers.17-19 Tobacco com- panies encourage tobacco use through marketing that reduces perceptions of harm associated with tobacco use and increases perceptions of social ac- ceptability.20-22 Previous analyses have shown that the tobacco industry has targeted older adults and marketed “light” and “low-tar” cigarettes as alter- natives to quitting with the false implication that they were healthier choices.8 Using a similar strat- egy, the tobacco industry has expanded its adver- tising of smokeless tobacco and e-cigarettes as alternative products for use in no-smoking areas and as aides to decrease smoking.23,24

The Emergence of E-cigarette Use in Older Adults

In the US, the prevalence of e-cigarette use is rising; in one study, 3.3% of adults in 2010 and 6.2% in 2011 had ever used an e-cigarette.25 In ad- dition, awareness of these products among adults increased from 40.9% in 2010 to 57.9% in 2011.25

Current cigarette smokers are more likely to use e-cigarettes than former or never smokers25 and in 2012, 76.3% of current e-cigarette users reported concurrent use of conventional cigarettes.26-29

There has been a dramatic increase in the sales of alternative tobacco and nicotine products (eg, smokeless tobacco, e-cigarettes, SNUS, snuff, chew, etc.) in California over the past 10 years, from $77.1 million in 2001 to $210.9 million in 2011.30 Whereas the use of smokeless products is

higher in younger populations, California adults using e-cigarettes in the past 30 days doubled from 1.8% in 2012 to 3.5% in 2013.25,30 Former and current smokers are more likely to be aware of and use e-cigarettes than never smokers.25

Research indicates that exposure to tobacco in- dustry marketing distorts perceptions about the availability, use, and risks of tobacco.31 Despite the importance of risk and benefit perceptions in decisions to use tobacco products, 32 most research has focused on adolescents or a general smoking sample, and has concentrated only on convention- al cigarette use.33,34 How older adults’ perceptions of e-cigarettes affect their tobacco use patterns (eg, initiation, re-initiation, continuation, cessation, product switching, dual use) is unknown.

E-cigarettes are marketed throughout the world as both a smokeless and safe alternative to con- ventional cigarettes, and as an aid for smoking ces- sation.35,36 Companies are marketing e-cigarettes as smoking cessation aids (Figure 1),36-39 and in response to these messages, some studies with significant numbers of participants over the age of 45 found that many people use e-cigarettes to try to stop smoking.27,41-43 In a 2013 study, among the 765 state quit line callers who had ever used e- cigarettes, the most reported reason for use was to help quit other tobacco (51.3%).43

E-cigarette Marketing and Renormalization of Smoking

Seeing the emergence of a multi-billion dollar market, the tobacco industry has invested heav- ily in e-cigarette production and marketing.44 Due to the lack of regulations over the marketing of e-cigarettes, the tobacco industry has revived television and radio marketing strategies, media channels that have been banned for more than 4 decades.40 A major public health concern is that, given the growing tobacco industry market share, e-cigarettes will be marketed on television, radio, and the Internet in ways that ultimately renormal- izes smoking of conventional cigarettes.38

Currently, there has been a resurgence in to- bacco industry advertising to encourage cigarette smokers to use e-cigarettes in no-smoking ar- eas and as an aid to quit tobacco cigarettes.23,24 Studies have demonstrated for decades that ex- posure to cigarette advertising is linked to smok- ing.45,46 E-cigarette advertisements are challenging a barrier to television promotion that has been in place for over 40 years. E-cigarettes mimic the personal experience and public performance of smoking, and marketing campaigns threaten to reverse the successful, decades-long public health campaign to denormalize smoking.47 Messages that renormalize smoking in public places are like- ly to appeal to older smokers who initiated smok- ing when it was ubiquitous and were, therefore, most impacted by bans on advertising and smok- ing indoors. Most research on tobacco marketing, risk perception, and smoking behavior has been

 

 

Note. Available at: http://newhere.com/blog/quit-smoking- electronic-cigarettes/. Accessed May 31, 2014.

Figure 1 Electronic Cigarette Blog Promotes E-cigarettes as

Smoking Cessation Devices

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done with adolescents and young adults who have not experienced tobacco advertising on television and were not alive when smoking was socially ac- ceptable.

E-cigarette Regulation Only a few state and local e-cigarette regula-

tions exist. Although the Food and Drug Admin- istration (FDA) does not currently regulate e-ciga- rettes, they have proposed to deem e-cigarettes as a tobacco product.48 The proposed rules will ban selling e-cigarettes to minors. It will not, however, ban Internet sales. Confusion about whether or not e-cigarettes are regulated has been document- ed among young adults49,50 and no data are avail- able for adults.

Although current public health efforts to pro- mote regulation of e-cigarettes is currently focused on youth,50-54 marketing messages that renormal- ize smoking in public places are likely to appeal to older smokers.31,55,56 The aims of this study were to: describe older smokers’ use of electronic ciga- rettes (e-cigarettes), characterize their perceptions of the risks and benefits associated with e-ciga- rettes, explore responses to marketing related to e-cigarettes, and describe older adults’ knowledge of, and opinions about, regulation of e-cigarettes.

METHODS This focus group study was the first phase of

a larger project to describe and understand the behaviors, perceptions, attitudes, and beliefs as- sociated with tobacco use (ie, conventional and new and emerging tobacco products) among older smokers (> 45 year old), especially dual users. For this study, 8-9 participants in 8 focus groups last- ing 90-minutes each met in urban and suburban California to discuss topics related to cigarettes and alternative tobacco products.

Participants were recruited using flyers and on- line classified advertisements. The study focused on smokers in California because of the state’s relatively low smoking prevalence and longstand- ing clean indoor air law.57 These laws have cre- ated an ideal climate for aggressive promotion of smokeless tobacco products and e-cigarettes to be

used in smoke-free environments. Inclusion crite- ria consisted of being: 45 years of age or older, a current smoker or one who quit within the last 2 years, able to speak English, able to read at the fifth grade level, without sight or hearing impair- ment, and able to tolerate a group session of 90 minutes duration. Participants provided informed consent for the study and audio recording, and completed a demographic questionnaire that in- cluded tobacco use history.

The groups were led by 2 members of the re- search team in a leased community space. The focus group discussions were semi-structured in which participants were open to explore other top- ics as they emerged in the discussion. Participants were asked to discuss their current tobacco use, current interest in quitting, and the places and situations in which they avoid smoking or use al- ternative tobacco products (Table 1). Participants were shown pictures and definitions of alterna- tive tobacco products including e-cigarettes, snus, chew, and dissolvables to elicit their perceptions of the benefits and risks of alternative tobacco prod- ucts, and to understand past and future use and future intentions to use such products. Partici- pants were asked to describe where they remem- bered seeing tobacco marketing. Participants were then shown ads for e-cigarettes to elicit emotional reactions to the ads, their perceptions of the ad- vertisement’s intended audience, and effectiveness in influencing conventional and e-cigarette use. At completion of the group, participants received a $40 gift card to a local department store.

Data Analysis A professional transcriptionist who was in-

structed to label each speaker turn as a separate paragraph transcribed the focus groups. Within Microsoft Word, we used the “convert text to table function” to convert the transcripts into a continu- ous vertical table of cells with each cell contain- ing one speaker turn. We then pasted these tables into a Microsoft Excel spreadsheet, adding col- umns identifying the date and location of the focus group, and numbering each speaker turn, or cell row. Thus, each speaker turn provided a unit of

Table 1 Focus Group Interview Guide

1. Please discuss your current tobacco use and the places and situations in which you: smoke, avoid smoking, or use alternate tobacco products. [Product List with pictures provided]

2. Describe your understanding of the potential risk or benefits – health related and social for cigarettes, smokeless tobacco, and e-cigarettes.

3. Tell me about your intention to use these products. [Product List with pictures provided] 4. In the last 30 days what tobacco advertising have you seen, where? 5. Please discuss your reactions to these ads and what do you think these ads mean? What effect would these ads have

on your tobacco use? [Pictures of advertisements provided]

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analysis for the application of codes varying in size from a single word to several paragraphs. To code these segments we created a column for each code, and indicated the presence of the code by adding the coder’s initials to the intersection of the seg- ment row and the code column.

This spreadsheet enabled us to view the data segments and the codes applied to them easily and in analytically useful ways. First, the transcripts were read in their original, sequential context. The segments were indexed into topical codes enabling us to see horizontal patterns in the co-occurrence of topics for each data segment. An initial 53 topi- cal codes were identified from the transcripts, and through discussions among the 3 coders, the code list was reduced iteratively to 42 as we combined topical codes having significant overlap (Table 2). By using their initials when coding segments, cod- ers were able to identify and discuss discrepancies in how each coder applied codes to each data seg- ment until we reached agreement.

When analyzing themes across segments on a

particular topic, we sorted rows by code to create collections of segments by topic of discussion. Final- ly, to ensure that we included all relevant segments in a collection, we searched for specific key terms (eg, nicotine, vape, ban, etc) across the focus group transcripts, and in this way, updated the coding un- til we were satisfied that transcripts had been coded adequately. Finally, we were able to refine our collec- tions by sorting the spreadsheet by combinations of codes, eg, “nostalgia” and “ads effective.” The pres- ent paper focused on segments coded as related to e-cigarettes, marketing, and regulation.

RESULTS The sample included 52 current and former

smokers, ages 45 to 68 (mean age 52.6 years; SD 6.1). Forty-seven (90.4%) of the participants were current cigarette smokers and 37 (71%) were male and 29 (58%) had an annual income of >40,000 USD. Ethnicity/racial identification included 26 (50%) White, 17 (33%) Black, and 9 (17%) identi- fied as other; 43 (83%) had at least some college.

Table 2 Topical Codes

Code Category Code

Speaker Turns Coded

Cessation Doctor Interaction 88 Cessation Successful Quit Attempt 63 Cessation Other Quit Methods 47 Cessation Unsuccessful Quit Attempt 43 Cessation Patch 28 Cessation Chantix 21 Cessation Fatalism 8 Cessation Not Currently Smoking 7 Cessation Wellbutrin 6 Consequences Health Effects 110 Consequences Lung Cancer 75 Consequences Addiction 67 Consequences Smell Bothersome 63 Consequences Second Hand Smoke 29 Consequences Cosmetic Effects 3 Contexts Nostalgia 147 Contexts Sex 50 Contexts Pot 48 Contexts Movies/Tv 47 Contexts Like About Smoking 32 Contexts Social Triggers 32 Contexts Sport 28

(continued on next column)

Table 2 (continued)

Code Category Code

Speaker Turns Coded

Contexts Alcohol 21 Contexts Class 19 Contexts Casino 18 Contexts Stress 15 Contexts Weight Control 1 Policy Ads Seen 336 Policy Warnings Impactful 219 Policy Smoking Ban 171 Policy Warnings Not Impactful 130 Policy FDA 100 Policy E Cig Ban 72 Policy Tob Regulation 69 Policy Taxes 39 Policy Lung Cancer Screening 28 Policy Price 12 Products E-Cig 558 Products Chew 125 Products Cigars 89 Products Strips/Orbs 70 Products Snus 60 Products Additives 37 Products Brand Loyalty 26 Products Menthol 25 Products Nicotine 20

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Use of E-cigarettes as a Cessation Aid Although not all smokers in the focus groups

had tried e-cigarettes, all reported that they were familiar with them and had seen advertising for e- cigarettes, and many planned to try them. Partici- pants were not asked specifically about vaporizers but they made the distinction that e-cigarettes are “for nicotine only” and look like “real cigarettes” and vaporizers “can use liquids other than nico- tine” and “look less like a cigarette” and “the fla- vors are to attract kids.”

Several participants stated that they did not know anyone who had successfully quit smoking with the use of e-cigarettes. However, when asked about intention, many said they could see using them in the near future either as an attempt to quit or for dual use:

“…using one of those to quit smoking…I do not know anybody that has done that. They just use it when they’re in doors. But they’re not quitting smoking. As soon as they go outside, they’re smoking regular cigarettes.”

“I think the e-cigarettes were supposed… to help someone quit. They have more nicotine than the regular packs of cigarettes. [So] it’s just to use… in places that you’re not allowed to smoke.”

“…my friend…he’s trying to quit …he’ll smoke one of those e-cigarettes for a couple months and then pick up a pack of cigarettes…And then he’ll be back on the e-cigarette the next couple of days. So…he’s been smoking both of them for about 2 years I think. So, I don’t see people stopping really.”

Although older smokers seem to be embracing e-cigarettes, they remain cynical about the health benefits and consequences. The following is an ex- change among participants:

“I distrust advertising in general, and corporate scumbags who are trying to sell us whatever product it is you consume that’s bad for us - just makes these things seem like lies to me. I’m not exactly sure what they’re trying to sell, other than that you can beat the smoking ordinances in your local city. I guess I had a misconcep- tion that they were selling them to quit smoking. It actually says, ‘Why quit?’ But, yeah, these are terrible. I’m not sure if this product is any healthier than cigarettes - maybe a little bit. But I distrust it.”

“Now, I don’t really believe anything the tobacco company says …I don’t know what’s in them [e-cigarettes], but something is in there to make you addicted…”

“I agree, 100%. Yeah, it could be nuclear waste for all they care.”

Flavors Older adults did not express an interest in fla-

vors (other than tobacco flavor) for e-cigarettes; they consistently associated flavors with youth and children:

“…the flavors are to attract kids” “Well, I tried the e-cigarettes… but they just haven’t captured or been able to manufacture a flavor of a real cigarette.”

“I’m kind of talking about the ones that don’t have flavor, that are, like, a waterless vapor that have no odor…A lot of the kids are doing the ones with the flavors…[like] blueberry, I see… more girls using them than guys, …espe- cially, you know, the flavored ones…”

“I think it’s also a risk where if somebody look[s] at it and think[s] oh it’s the cool thing. But they’re not a smoker currently. I hate using that term pathway but it can easily move them over to - a pack of cigarettes is $5 and one of these [e-cigarettes] is $12. …They’re changing the fla- vors on them too … to get high school kids.”

Perceived Benefits of E-cigarettes Discussions often returned to the topic of past

failed smoking cessation attempts and the hope that e-cigarettes might be the answer “the thing that finally works.” Even though none of the par- ticipants had quit smoking with e-cigarettes, or even knew someone who had quit, many still saw e- cigarettes as a viable choice for smoking cessation:

“Well, I haven’t tried them yet, but I think that the next time I quit that I will probably try them because I have friends who have tried them...”

A cited benefit was cost:

“…they are cheaper than other cessation aids”

and

“those e-cigarettes, they’re like 30 bucks a piece…but anything [else] that helps you quit is really, really expensive.”

Healthier alternative to cigarettes. Gener- ally, participants agreed that e-cigarette advertise- ments promoted the perception that e-cigarettes are less risky than conventional cigarettes. The lack of government warnings about e-cigarettes was seen as an endorsement of the claim that they are a healthier alternative to cigarettes.

“I mean there was one that I saw, oh no tar. So, people think oh I can be safer with this…a healthy alternative to smoking real cigarettes… .I see that advertising too where they try to say

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it’s a healthy alternative.”

“Well from the ads …I don’t see many warnings at all. It’s almost like they were saying …this is the pleasurable thing to do. Have a good time. … I didn’t see any warnings.”

For use in no-smoking areas. The perception that they could be used anywhere, regardless of smoke-free policies, was described as a major ad- vantage to e-cigarettes:

“I thought they were a great idea, because you can do it at work. You can do it anywhere…so that really pushed me further to want to inves- tigate it more.”

Another participant agreed:

“If you’re somewhere you’re going to be for a long time you know you can’t smoke. I think… these would be a substitute for a cigarette. So, it would help you with the no-smoking rules.”

Smoking with social acceptance and no sec- ond hand smoke. The use of e-cigarettes was seen as a way to continue smoking, or at least have the tactile experience of smoking, without being so- cially isolated, because there is “no smell” and “no second hand smoke.” One participant described how e-cigarettes helped her regain the feeling of inclusion in discussions with other smokers:

“I could still be a part of the community, [when I quit] conversations happened outside with the people who were smoking, and many of them were people that I love dearly and I wasn’t a part of those [conversations].”

Perceived Risks/Disadvantages of E-cigarettes The perceived risks and disadvantages of e-ciga-

rettes were mostly related to the unknown nature of e-cigarettes and included the lack of scientific evidence about safety, unknown levels of nicotine with a question of satisfaction, and possible dan- gers such as volatility (ie, explosions) and physical reactions.

Lack of scientific evidence. There was a gen- eral consensus that e-cigarettes were appealing despite uncertainties:

“It’s kind of scary, because they’re a new prod- uct, and it’s hard to know, you know, if it’s worse for you than cigarettes actually are…I’m not sure. I think they just haven’t done enough studies on the use of those to see if they hurt you or not”

and

“You don’t know what’s in it…but there are chemicals in the reaction…They don’t have to

tell you. So, you don’t know what those chemi- cals are.”

Unknown levels of nicotine. Everyone was aware that e-cigarettes had nicotine but they did not like that they were unable to gauge how much nicotine exposure they were receiving and they complained of lack of satisfaction.

“…I’m not able to tell how many cigarettes I’m smoking, you know…if I smoke on these for 5 minutes, then [have] I had one cigarette? …I don’t want to smoke 5 in a row. I just want to smoke one cigarette.”

Mechanical dangers. All participants had heard or seen news reports of e-cigarette mechani- cal dangers that included mishaps and explosions:

“Well, it’s not tobacco that you’re smoking. No harmful tobacco in your lungs, but they blow up every once in a while,”

and referring to a different report,

“… their jaw came off and he blew up his nose too…I’d rather smoke than have my face blown off.”

Comparative cost with conventional ciga- rettes. Although e-cigarettes are advertised as less expensive than conventional cigarettes, there was confusion about their cost-effectiveness. Whereas some perceived e-cigarettes as expensive,

“Those e-cigarettes, they’re like 30 bucks a piece…”

“...it’s expensive…Yeah because one is like $11,”

and

“They run out. You’ve got to keep buying them right? You have the main cigarette and then there’s a little …filtered part is what you have to keep buying and they’re like 10 bucks for like 5 of 6 cartridges.”

Others perceived e-cigarettes as less expensive than conventional cigarettes:

“So, one cartridge a day is about $2 a day, so it’s a lot cheaper. So, it’d be 14 bucks a week, 7 days a week.”

This discrepancy was present among all focus groups.

E-cigarette Marketing and Vaporizers Participants were not asked specifically about

vaporizers but they made the distinction that e-

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cigarettes are “for nicotine only” and look like “real cigarettes” and vaporizers “can use liquids other than nicotine” and “look less like a cigarette” and “the flavors are to attract kids.”

Anybody, everybody is using them [vaporiz- ers]. Participants spoke of wide spread use of va- porizers among older adults:

“A lot of people, over 45 have them. … you can put whatever you want in them…You can buy a big jug of nicotine oil… They’re so popular.”

[Moderator asked: ‘Younger people do these things?’] “No, anybody, everybody.”

Renormalization of Smoking There was a consensus that e-cigarette adver-

tising promoted dual use of conventional tobac- co products and electronic smoking because the products look similar in appearance. There was almost unanimous agreement that the current e- cigarette advertisements contributed to the renor- malization of smoking because images are nearly indistinguishable from conventional cigarettes and the ads promoted smoking as a socially desirable behavior:

“It’s making smoking normal again…” and “Like, they’re not trying to get you to quit -- in fact, they’re trying to encourage you …so you smoke more…”

The appeal of nostalgia as a marketing tool. Participants discussed the nostalgic tone of the e- cigarette ads and how they reminded them of ad campaigns of their youth featuring bowling alleys and nightclubs.

“…definitely [targeted for] a more mature crowd because you have…Hennessy or brandy… that’s something -- a more mature crowd would probably consume. And the pack, it’s like… the Marlboro man had.”

“Like… when it was okay to smoke everywhere, it’s like they took the same campaigns and put an ‘E’ in front of the cigarette. Okay, we’re starting all over again. Same people, same cam- paigns, just put an ‘E’ in front of it and it’s okay. But these pictures are almost identical [to those] they used back in the ‘70s.” The nostalgic appeal of the ads to older smokers

is exemplified by the Fin (an e-cig company) tag line: “Welcome Back” with pictures of mid-centu- ry diners and living room interiors photographed from a child’s perspective (Figure 2).

“… [for] people who may have quit, these ideas are sort of like a comfortable environment of the days of past are here again…”

Participants described their surprise in seeing

e-cigarette ads appear on cable television. By de- ploying their ads on television, e-cigarette market- ers are effectively tapping into the nostalgia of our focus group participants who reminisced with each other by repeating the tag lines and jingles of ciga- rette ads from the 1960s and 1970s.

Participants recalled a time before warning labels and advertising restrictions on tobacco products. The reminiscence provided them with a historical view of the ways that the industry has adapted its marketing tactics over the decades. Distrust of the tobacco industry was expressed:

“I think it’s the big tobacco companies behind e-cigs. I think they’re trying to cover every base they can.”

Regulation of E-cigarettes Several discussions addressed the lack of warn-

ing labels and confusion about the legal status of e-cigarettes, opinions differed about the need for

 

 

Note. Available at: www.trinketsandtrash.org. Accessed May 31, 2014.

Figure 2 E-cigarette Ad with the Slogan

“Welcome Back,” Depicting a Diner with a 1960s’ Décor Shot at the Vantage Point of a 2nd-grader,

Suggesting they Might be Targeting People Who were ~7 years Old circa

1964

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368

e-cigarette regulation.

“Well from the ads I can see compared to the old cigarette Surgeon General warning I don’t see many warnings at all. It’s almost like they were saying about this particular guy with the e-ciga- rette, this is the pleasurable thing to do. Have a good time. Don’t worry about people seeing you smoke. I didn’t see any warnings.”

There was confusion about age limits and wheth- er e-cigarettes were banned:

“Yes, I believe you have to be 18...you do have to show ID. For the Blu ones…I don’t know about the other ones.”

“…I think I saw about them legislating a law for e-cigarettes”

and

“…as far as regulation, if it says cigarette on it they regulate it. But if it’s just a vaporizer, even if it’s filled with tobacco or nicotine, anybody can buy it as long as it doesn’t say cigarette on it.”

DISCUSSION This is the first study known to provide insight

into risk and benefit perceptions of older adults re- lated to the use of e-cigarettes. Our results suggest that older adults are interested in e-cigarettes and vaporizers and they are using them in increasing numbers as a cessation aid and as a way to cir- cumvent no-smoking policies. Older smokers were

unclear about the effectiveness, safety and risk, or benefits of e-cigarettes, likely due to misleading advertising.

Some ads target older adults and highlight the possible health benefits of e-cigarettes; some even suggest that e-cigarettes may prevent Alzheimer’s Disease (Figure 3). Some participants believed that e-cigarette advertising promoted e-cigarettes as being beneficial for health. Many were hopeful but they were also skeptical about the benefits and safety of e-cigarettes. There was almost unanimous agreement that current e-cigarette advertising pro- moted use of cigarettes to circumvent no-smoking laws and that the images used contributed to the renormalization of smoking.

The limitations of this study are inherent to qualitative methodology. This study was designed to be a first step toward characterizing e-cigarette use and risk perceptions among older adults. Al- though important, it is unknown if the identified themes are relevant to all older smokers or are just findings relayed by an older audience. Because of the design, sample size, and the geographical limi- tation, the results are not generalizable.

Further studies are needed. Because of smoking prevalence in this group, and the extended time between initiation of smoking and appearance of disease, older adults are disproportionately af- fected by tobacco related diseases. Older smokers’ perceptions of e-cigarette marketing reflect their formative smoking experiences and their percep- tions of the experiences of others. Therefore, older adults’ perceptions differ from ones of younger co- horts, making this an important population to be studied in relation to risk and benefit perceptions and use of e-cigarettes. A larger national quantita- tive survey study is indicated. In addition, random- ized control trials with large samples are needed to determine if e-cigarettes are an effective cessation aid or an ultimate deterrent from quitting.

Relapse is a salient feature of nicotine addic- tion and most older smokers have a long history of smoking cessation attempts and failures.57 They have tried various cessation aids, and e-cigarettes present as the latest hope for smoking cessation. However, a tension exists between hoping for a successful cessation aid and having lived through the experience of being “duped” by the tobacco in- dustry – many older smokers started smoking be- fore the harms were publically exposed. Therefore, although older smokers seem to be embracing e- cigarettes, they remain cynical about the health benefits and consequences.

Our results add support to previous findings that older adults are not experiencing success- ful cessation with e-cigarettes. Despite tobacco industry marketing messages asserting that e- cigarettes are effective cessation aids, in a pro- posed deeming rule, the FDA stated: “There is no evidence to date that e-cigarettes are effective cessation devices.”43 A meta-analysis of 5 popu- lation studies found significantly lower odds of

 

   Note. Available at: http://spinfuel.com/vaping- news/?s=Alzheimer. Accessed October 31, 2014.

Figure 3 Could E-cigarettes Someday be Used

to Combat Alzheimer’s Disease?

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quitting (OR = 0.61, 95% CI 0.45–0.83) among adult smokers who had used e-cigarettes, com- pared to those who had not.44 Older adults may perceive marketing messages differently than younger smokers who are not subject to the same nostalgia and cynicism. The anachronistic imag- ery and use of previously banned media such as television, make e-cigarette ads especially salient for older smokers who remember the days when smoking and cigarette advertising were ubiqui- tous and unrestricted. Like “low-tar” cigarettes, e-cigarettes are similarly marketed to older smok- ers as a healthier alternative to conventional ciga- rettes. One systematic content analysis of e-cig- arette website marketing found that 95% of the websites made explicit or implicit health-related claims and 64% had a smoking cessation claim.40

Our findings demonstrate the confusion ex- pressed by older smokers about regulation of e- cigarettes. One reason for this may be that some e- cigarette products erroneously bear the FDA label (Figure 4). Whereas the Family Smoking Preven- tion and Tobacco Control Act explicitly prohibits use of “FDA-approved” language for marketing of tobacco products, this restriction currently does not apply to e-cigarettes.

In summary, older smokers’ perceptions of e- cigarette marketing reflect their formative smoking experiences. Most older smokers began smoking at a time when cigarette ads and smoking behaviors were ubiquitous. Therefore, older smokers are an important segment of the population that should be studied as a distinct sub-group. Further research is needed to identify the impact of marketing mes- sages, particularly aggressive new advertising pro- moting e-cigarettes as cessation aids and for dual use to cope with smoke-free environments. These findings suggest that to stem the current epidemic of nicotine addiction, the FDA must take immediate action. E-cigarette advertisements use unsubstan- tiated claims that have the potential to undermine cessation attempts of adults. The FDA’s final rule, Regulations Restricting the Sale and Distribution of Cigarettes and Smokeless Tobacco to Protect Children and Adolescents59 and the Master Settle- ment Agreement60 already prohibit many of these exploitive techniques for cigarettes and smokeless tobacco. The FDA should use its authority to is- sue regulations requiring restrictions on the sale and distribution of e-cigarettes for the protection of public health.

Conflict of Interest Statement The authors declare that there is no conflict of

interest.

Human Subjects Approval The institutional review board at the University

of California, San Francisco approved this study.

Acknowledgment Research reported in this publication was sup-

ported by grant number 1P50CA180890 from the National Cancer Institute and Food and Drug Ad- ministration Center for Tobacco Products. The con- tent is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Food and Drug Administration.

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