Background: E-cigarettes (EC) are the most commonly used tobacco product among youth. Additionally, youth EC users are progressing to smoking conventional cigarettes (CC). Although known to target youth, there are no current restrictions in the US on EC marketing, including advertising. The purpose of this study is to evaluate the relationship between EC advertisements and youth EC and CC use behaviors.

Methods: This study analyzed data from youth (12-17 years) aware of EC in Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) study (n=12,199). Weighted logistic regression models assessed whether exposure and receptivity to any of five randomized EC ads (two TV and three print) were associated with the outcomes of EC and CC behaviors of ever use, current (past 30 day) use, and susceptibility to future use. Additional analyses determined whether EC advertising exposure and EC and CC behaviors associations were moderated by EC advertising receptivity. All models were adjusted for sociodemographics, other combustible tobacco product use, and parent smoking.

Results: EC advertisement exposure was significantly associated to ever and current EC use as well as susceptibility to EC and CC (p

Conclusion: These findings demonstrate exposure to EC advertisements are particularly associated with EC use behaviors, but could play a role in future CC use as well. Youth who are receptive to EC advertisements appear particularly vulnerable. Further studies should focus on the role of receptivity to EC advertisements among youth in order to support regulatory policy targeting EC advertising.

Key Take Away Points

• EC advertisement exposure was positively associated with EC use behaviors and susceptibility to future CC use among a nationally representative sample of youth. • There is a need to focus research on the moderating role of receptivity to EC advertisements among youth, as youth receptive to EC advertisements particularly vulnerable to EC and CC use behaviors. • Policies limiting exposure to EC advertising are an important component of tobacco prevention efforts.

Author Biography

Nicole E. Nicksic, Ph.D., MPH is a postdoctoral research fellow in the Center for the Study of Tobacco Products (CSTP) and the Department of Health Behavior and Policy at Virginia Commonwealth University (VCU). Dr. Nicksic earned her B.S. in Clinical Laboratory Science and Sociology from the University of Wisconsin at Madison. She worked as a medical technologist in a hospital laboratory in Milwaukee, WI before beginning her graduate work at the University of Texas School of Public Health at the Austin campus to earn a Master of Public Health (MPH) and PhD in Epidemiology. During her time at UTSPH, Dr. Nicksic gained experience in the areas of obesity, tobacco control, and adolescent health as well as behavioral sciences, global health, occupational and environmental epidemiology, and quantitative analyses. While earning her MPH, Dr. Nicksic led research efforts in daycare centers and elementary schools on obesity, nutrition, and physical activity in the Dell Center for Healthy Living. During her doctoral program, Dr. Nicksic transitioned to the Tobacco Center of Regulatory Science (TCORS) on Youth and Young Adults, focusing her research on e-cigarette use behaviors among youth. She also received a TCORS pilot grant to research hookah use, perceptions, and receptivity to warning labels among young adults. As a postdoc, she continues to conduct research on the relationship between e-cigarette advertising and tobacco use behaviors and implications for policy as well as present her work at multiple conferences and lead publications for peer-reviewed journals. Morgan Snell, MPP is a doctoral student in the Department of Health Behavior and Policy at Virginia Commonwealth University. She received her Master of Public Policy (MPP) degree and B.A. in Media Studies from the University of Virginia, where her research focused on communication and health disparities in Central Virginia as well as social impact bonds and workforce development throughout Virginia. Her current research focuses primarily on health disparities and tobacco policy. Andrew J. Barnes, Ph.D. is an Associate Professor of Health Behavior and Policy at Virginia Commonwealth University (VCU), Research Associate of the VCU Massey Cancer Center, and affiliate faculty in the VCU Center for the Study of Tobacco Products. His research interests include: 1) health policy, 2) cancer care delivery research, and 3) behavioral economics and patient decision-making. Dr. Barnes is currently working with a team of researchers on the effects of federal and state regulations on e-cigarette use, how preferences impact decision-making in cancer, and several projects related to health insurance decision-making. Dr. Barnes is the co-author of the book Healthcare Systems in Transition: United States of America and co-editor of the upcoming book Behavioral Economics and Health Behaviors: Key Concepts and Current Research. He completed his doctoral training in health policy with a concentration in economics at the University of California, Los Angeles and holds a Masters of Public Health from Tulane University.


Dr. Nicksic's effort was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number P50DA036105 and the Center for Tobacco Products of the U.S. Food and Drug Administration. The content is solely the responsibility of the authors and does not necessarily represent the views of the NIH or the FDA.