How marijuana co-marketing contributes to dual and concurrent use of marijuana and tobacco warrants study, particularly for youth and young adults. In previous research, the prevalence of adult marijuana use in 50 California cities was positively correlated with the retail availability of blunts. Whether this is correlated with blunt use by adolescents is not yet known. Consumer perception studies are necessary to assess whether marijuana co-marketing increases the appeal of cigar smoking or contributes to false beliefs about product ingredients. Research is also needed to understand how the tobacco industry exploits opportunities for marijuana co-marketing in response to policies that restrict sales of flavored tobacco products and to policies that legalize recreational marijuana use. Such assessments are essential to understand young people’s use patterns and to inform current policy concerns about how expanding retail environments for recreational marijuana will impact tobacco marketing and use.Use of non-cigarette tobacco is increasing among youth. Past 30-day use of electronic cigarettes among US high school students recently rose substantially, more than doubling in two years, from 11.7% in 2017 to 27.5% in 20191,2. Similarly, the use of conventional smokeless tobacco in 2018 nearly equaled the prevalence of cigarette smoking among male US high school students 1 . Use of e-cigarettes and smokeless tobacco exemplify a larger trend,cannabis equipment in which a broadening range of non-cigarette and non-combustible tobacco products threatens to erode public health gains in reducing youth tobacco use.
Tobacco product characteristics, such as flavors, nicotine strength, e-cigarette device type , or smokeless tobacco cut , can signal properties of tobacco products to potential consumers, including youth. Perceived properties might relate to the taste, potency, or relative safety of the product. To the extent that specific tobacco product characteristics lead to youth viewing certain tobacco products as more appealing or associated with fewer risks, those characteristics represent plausible targets of regulation or other restrictions intended to reduce youth use. A combination of branding, product design, and real or perceived properties likely operate individually and collectively to shape youth tobacco related attitudes and decision-making. Research that identifies and quantifies the contributions of specific tobacco product characteristics is potentially appealing to regulators seeking to reduce youth use without outright bans on entire classes of products. Discrete choice methods stem from economic theory that consumer preferences are based on the multiple intrinsic characteristics of goods or products3 , and have recently been applied to tobacco control and tobacco regulatory science4 . Discrete choice experiments are designed to identify the independent contributions of component parts of a good or service to potential consumers’ overall preferences and/or beliefs. In surveys, participants are often asked to choose between two different products or scenarios, each representing a composite set of relevant attributes at varying levels , allowing quantification of how these characteristics independently contribute to respondents’ choices. Recent work has examined adults’ preferences related to waterpipe tobacco and e-cigarettes, as well as youth e-cigarette preferences. In the latter study, youth were more likely to prefer e-cigarettes with non-tobacco flavors and less likely to choose products with Food and Drug Administration warning labels or ‘cigalike’ devices. The present study expands on previous discrete choice studies by including a community-based sample of youth, assessing both e-cigarettes and smokeless tobacco, and considering multiple specific perceived properties, such as danger and ease of use.
The study objective is to evaluate the extent to which specific characteristics of e-cigarette and moist snuff smokeless tobacco products convey product qualities to youth, especially those perceived qualities that may lead to greater youth appeal and product use. Such product characteristics are plausible targets of potential FDA regulation or local policy designed to reduce youth tobacco use. Based on prior work showing favorable perceptions and disproportionately higher use levels of flavored tobacco use among youth and young adults, we hypothesize that flavored tobacco, independent of other product characteristics, will be associated with greater curiosity and ease-of-use but lower perceived danger and potency, both for e-cigarettes and moist snuff. As an exploratory objective, we additionally examine differences in the association between product attributes and youth perceptions by gender and tobacco use status. This discrete choice experiment was embedded in the UCSF Adolescent Tobacco and Health Study, an in-person, school-based survey of high school students recruited from grades and in Northern and Central California. The overall survey included items about current and past tobacco use, perceptions of new and emerging tobacco products, socio-environmental variables, health conditions, and use of other substances as part of an overarching goal to assess factors influencing tobacco-related behaviors over time in this population. Thus, the present analysis is crosssectional and experimental . An Institutional Review Board at the University of California San Francisco reviewed and approved all study procedures. Participating students received a $10 gift card to an online retailer. Participating schools received $300. Overall study enrollment and survey administration took place from March 2019 to February 2020 at public high schools. Due to limited classroom time, the final school completed a shortened questionnaire that excluded discrete choice items. Thus,schools recruited from March 2019 to January 2020 were included. Eligible schools were located in municipalities with fewer than 50000 residents and in counties of population density less than 1000 persons/ square-mile11.
Schools were selected for participation via purposeful sampling that targeted counties with expected higher levels of tobacco use and where the investigative team had existing collaborative research relationships. All grade 9 and 10 students at participating schools were eligible to participate. Study staff visited all sessions of a required course to explain study objectives and distribute parental consent and student assent forms, followed by in-class administration of the electronic survey on computers 1–2 weeks later. As a programmed feature of the survey software , students were randomized at the participant level with equal probability to one of two discrete choice experiments: e-cigarettes or moist snuff smokeless tobacco. Participants randomized to the e-cigarette experiment were presented six pairs of randomly generated hypothetical e-cigarette products under a full factorial design. The composite products differed in device type , flavor , vapor cloud , and nicotine amount . Prior to viewing the computer generated composite e-cigarettes, participants were shown an image containing the possible e-cigarette product characteristics they might see . Participants randomized to the smokeless tobacco discrete choice experiment were presented six separate, consecutive pairs of randomly generated hypothetical moist snuff products under a full factorial design. The composite products differed in brand , flavor , cut , and price . Prior to viewing the computer-generated composite moist snuff products, participants were shown an image containing the possible moist snuff product characteristics they might see . The number of displayed characteristics and their levels were necessarily constrained to avoid excessive cognitive burden. Some characteristics were product specific . Prioritizing which characteristics to retain for each product was based on existing qualitative and quantitative literature on youth tobacco-related perceptions and use motivations. In each experiment, for each pair of product composites, participants were asked which product ‘are you more curious about’, which ‘is more dangerous to health’, which ‘would be easier to use’,vertical grow shelf and which ‘would give a bigger ‘buzz’ or ‘head rush’’. These outcomes were chosen because of previous work showing associations between tobacco use and/or susceptibility with youth-reported curiosity, perceived danger, and perceived ease-of-use The outcome ‘buzz’ was introduced to measure perceived physiological effects or potency. Participants could select either composite product within the pair or ‘neither of these options’. Supplementary file, Figure A3 shows an example question layout. Of 1052 eligible participants, 525 took part in the e-cigarette discrete choice experiment and 522 the moist snuff discrete choice experiment . Participants providing ‘straight-line’ responses with no variation in choosing the left hand-side or right hand-side product were excluded to improve data quality, leaving 495 in the e-cigarette experiment and 508 in the moist snuff experiment.Conditional logistic regression was used to quantify the independent contribution of product attributes to participants’ choices while maintaining the matching of each pair. The position of the composite product on the screen was also included in models to account for possible ordering preference. A positive regression coefficient indicates how much the attribute level in question increased the log-odds of that composite product being chosen relative to the reference level , holding all other product attributes constant. Negative coefficients indicate how much that characteristic independently decreased the log-odds of being chosen.
All models used the cluster-robust variance option to account for multiple items per participant. Interaction terms were added to models to assess differences according to participant gender and history of tobacco product use . Differences by gender and tobacco use were assessed in separate models. Likelihood ratio tests were performed to assess the overall improvement in model fit by adding interaction terms. Both main effects and interactions were considered statistically significant if 95% confidence intervals excluded the null value, without adjustment for multiple hypothesis tests.Participants in the e-cigarette discrete choice experiment and in the smokeless tobacco experiment did not differ from each other in their aggregate demographic characteristics or tobacco use . Approximately half the sample identified as female, Hispanic/Latinx, and as eligible for free or reduced cost school lunch . E-cigarettes were the most commonly used tobacco product , whereas a smaller percentage used smokeless tobacco products . In the e-cigarette experiment , tank-type and pod-type devices garnered more curiosity and were perceived as easier to use than cigalike or dripmod devices. Relative to tobacco flavor, all flavors were associated with more curiosity, less perceived danger, and greater perceived ease-of-use. On the adjusted log-odds scale, where tobacco flavor is the reference, fruit and dessert were most positively associated with curiosity, while mint and unicorn were the flavor options most negatively associated with danger. Smaller vapor cloud e-cigarettes were viewed as less dangerous, offering less buzz, and easier to use.High nicotine devices were viewed with less curiosity, as more dangerous, delivering more buzz, and less easy to use, relative to low nicotine or nicotine-free devices . In the moist snuff experiment , one brand was perceived as the most dangerous but also the easiest to use. Relative to tobacco flavor, all moist snuff flavors were associated with more curiosity, less perceived danger, and greater perceived ease-of use. On the adjusted log-odds scale, fruit and mint flavors were the characteristic levels associated with the most curiosity, while fruit flavor was also viewed as offering the least buzz . Associations of modest magnitude suggested that fine cut products were perceived as less dangerous and offering less buzz. Higher price products were viewed with more curiosity, as more dangerous, offering a greater buzz, and being less easy to use . Among all responses, the probability of choosing ‘neither of these options’ rather than selecting one of the two composite products varied by product and the question being asked. In the e-cigarette experiment, participants indicated ‘neither’ most often when asked about which of the two products they were more curious . ‘Neither’ was less often selected when asked about ease of use , buzz , and danger . Similarly, in the smokeless tobacco experiment, ‘neither’ was indicated most often when asked about curiosity , followed by ease-of-use , buzz , and danger . There was no statistically significant interaction by gender in the e-cigarette experiment . In contrast, having ever used an e-cigarette was associated with differences in all four perception outcomes . E-cigarette ever users held stronger perceptions about device types, viewing tank-type and pod-type devices with more curiosity relative to cigalike devices than did never users. Both e-cigarette ever and never users perceived flavored products with more curiosity and as easier to use compared to tobacco flavored products, but only never users believed that flavored products delivered less buzz than tobacco flavored e-cigarettes. Likewise, only never users were less curious about higher nicotine content e-cigarettes . In the moist snuff experiment, the direction and magnitude of associations were similar by gender, but there was nominally statistically significant interaction for the outcomes curiosity and danger, as male participants indicated more curiosity about higher price products . Only 44 smokeless tobacco ever users completed the moist snuff experiment, limiting statistical power to detect differences in association by product use. Generally, brand perceptions were stronger among smokeless tobacco ever users. Only never users viewed flavored products as offering less buzz and as easier to use, whereas only ever users associated pouched products as easier to use .This study provides quantitative evidence that specific characteristics of non-cigarette tobacco products independently shape how youth perceive these products.