An experimental study of the effects of electronic cigarette warnings on young adult nonsmokers' perceptions and behavioral intentions

Background: Electronic cigarette ("e-cigarette") manufacturers use warning labels on their advertising that vary widely in content and the U.S. Food and Drug Administration has issued a warning label requirement for e-cigarettes. There is limited data on the effects of these warnings on e-cigarette perceptions and other potential predictors of future tobacco use behavior in populations of interest to inform future regulatory requirements. This study examined the effects of e-cigarette warnings on perceptions of e-cigarettes and cigarettes and other cognitive precursors to tobacco use among young adult non-smokers. Methods: Non-smoking young adults ages 18 to 30 years (n = 436) were recruited through an internet-based crowdsourcing platform for an online experiment. Participants completed pre-exposure measures of demographics, tobacco use, and other relevant constructs and were randomized to view 1 of 9 e-cigarette stimuli in a 3 (Ad/Warning condition: Ad Only, Ad with Warning, Warning Only) x 3 (E-cigarette brand: Blu, MarkTen, Vuse) design. After viewing e-cigarette stimuli, participants reported perceptions of e-cigarettes and behavioral intentions to use e-cigarettes. Participants in the Ad Only and Ad with Warning conditions also completed a heat-mapping task assessing aspects of the ads that captured their attention. Then, participants were randomized to view cigarette ads from 1 of 3 major cigarette brands and reported perceptions of cigarettes and intentions to smoke cigarettes. Results: Participants in the Warning Only condition reported significantly greater perceived harm and addictiveness of e-cigarettes and thoughts about not using e-cigarettes than the Ad Only and Ad with Warning conditions (p's <.05). The Ad Only and Ad with Warning conditions did not differ on these outcomes. Participants in the Warning Only condition also reported the harms of e-cigarettes were closer to those of cigarettes than the Ad Only condition (p <.05), but neither differed from the Ad with Warning condition. Visual inspection of heat-mapping task data indicate warnings drew few participants' attention. There were no significant differences across study conditions on perceptions of cigarettes or intentions to smoke. Conclusions: Text-based warning messages influenced young non-smokers' perceptions in a way that may dissuade e-cigarette use, but warnings appearing on advertisements had little impact.