Exposure to Electronic Cigarette Advertising Among Middle and High School Students — United States, 2014–2016

Electronic cigarettes (e-cigarettes) are the most commonly used tobacco product among U.S. middle and high school students (1). Exposure to e-cigarette advertisements is associated with higher odds of current e-cigarette use among middle and high school students (2–4). To assess patterns of self-reported exposure to four e-cigarette advertising sources (retail stores, the Internet, television, and newspapers and magazines), CDC analyzed data from the 2014, 2015, and 2016 National Youth Tobacco Surveys (NYTSs). Overall, exposure to e-cigarette advertising from at least one source increased each year during 2014–2016 (2014: 68.9%, 18.3 million; 2015: 73.0%, 19.2 million; 2016: 78.2%, 20.5 million). In 2016, exposure was highest for retail stores (68.0%), followed by the Internet (40.6%), television (37.7%), and newspapers and magazines (23.9%). During 2014–2016, youth exposure to e-cigarette advertising increased for retail stores (54.8% to 68.0%), decreased for newspapers and magazines (30.4% to 23.9%), and did not significantly change for the Internet or television. A comprehensive strategy to prevent and reduce youth use of e-cigarettes and other tobacco products includes efforts to reduce youth exposure to e-cigarette advertising from a range of sources, including retail stores, television, the Internet, and print media such as newspapers and magazines (5).

Data were analyzed from the 2014, 2015, and 2016 NYTSs, a cross-sectional, paper-and-pencil survey administered to U.S. students in grades 6–12.* NYTS utilizes a three-stage cluster sampling design to generate a nationally representative sample of public and private school students. Sample sizes and response rates for 2014, 2015, and 2016 were 22,007 (73.3%), 17,711 (63.4%), and 20,675 (71.6%), respectively.

Participants were asked “how often do you see advertisements or promotions for electronic cigarettes or e-cigarettes” from the following four sources: 1) “when you are using the Internet”; 2) “when you read newspapers or magazines”; 3) “when you go to a convenience store, supermarket, or gas station”; and 4) “when you watch television or go to the movies.” Movies were omitted from the question after 2014. Response options for each question were “I do not [use/visit the source]”; “never”; “rarely”; “sometimes”; “most of the time”; and “always.” Consistent with previous research, students who reported “sometimes,” “most of the time,” or “always” were classified as “exposed” to advertisements from each source; those who selected “never,” “rarely,” or “I do not [use/visit the source]” were classified as “not exposed” (6). The number of exposure sources were summed for each student and reported as the percentage of all students who were exposed to one, two, three, or four sources.

Data were weighted to account for the complex survey design and adjusted for nonresponse. Prevalence estimates and 95% confidence intervals of exposure to each source, and to any source, were computed. Estimates of exposure were assessed overall and by sex, race/ethnicity, school grade, current (past 30-day) use of e-cigarettes, and current (past 30-day) use of any other tobacco product.^† Within each year, t-tests were used to assess statistically significant differences between levels of each covariate relative to the referent group (p<0.05). Between-year differences in the overall percentage of students exposed to each advertisement source during 2014–2016 were assessed using the Wald F test and posthoc corrections for multiple hypothesis testing (p<0.0167).^§

Among U.S. middle and high school students during 2014–2016, exposure to e-cigarette advertisements from any source increased from 68.9% (18.3 million) to 78.2% (20.5 million) (Figure 1) (Table). In 2016, exposure was highest for retail stores (68.0%, 17.7 million), followed by the Internet (40.6%, 10.6 million), television (37.7%, 9.7 million), and newspapers and magazines (23.9%, 6.2 million). In 2016, exposure to advertising from any source was more prevalent among females (79.9%) than males (76.5%); non-Hispanic whites (79.6%) than Hispanics (77.0%) and students of other non-Hispanic races/ethnicities (73.6%); 8th (78.5%), 10th (81.0%), 11th (79.3%), and 12th graders (79.0%) than 6th graders (75.0%); high school students (79.2%) than middle school students (76.9%); current e-cigarette users (82.8%) than nonusers (77.9%); and current users of other tobacco products (82.7%) than nonusers (77.6%). Exposure to each advertising source was higher among current e-cigarette users and other tobacco product users than nonusers during 2014, 2015, and 2016 (Table).

Overall in 2016, 28.3% of students reported exposure to e-cigarette advertising from one source, 21.2% from two sources, 16.7% from three sources, and 12.0% from four sources (Figure 2). Retail stores were the most common exposure source every year (2014: 54.8%; 2015: 59.9%; 2016: 68.0%), whereas newspapers and magazines were the least common exposure source (2014: 30.4%; 2015: 31.0%; 2016: 23.9%). The Internet was the second most common exposure source in 2014 (39.8%) and 2016 (40.6%); in 2015, television (44.5%) exceeded the Internet (42.6%) as the second most common exposure source.

During 2014–2016, middle and high school students’ exposure to e-cigarette advertising significantly increased for retail stores (from 54.8% to 68.0%), significantly decreased for newspapers and magazines (from 30.4% to 23.9%), and did not significantly change for Internet and television.

Corresponding author: Kristy Marynak, KMarynak@cdc.gov, 770-488-5493.

¹Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

References

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FIGURE 1. Percentage* of U.S. middle and high school students exposed to e-cigarette advertisements through any source,^† retail stores,^§ the Internet,^¶ television/movies,** and newspapers and magazines^†† — National Youth Tobacco Survey, United States, 2014–2016

* Between-year differences in the percentage of students exposed to each advertisement source during 2014–2016 were assessed using the Wald F test and posthoc corrections for multiple hypothesis testing (p<0.0167).

^† Statistically significant increases occurred during 2014–2015, 2015–2016, and 2014–2016.

^§ Statistically significant increases occurred during 2014–2015, 2015–2016, and 2014–2016.

^¶ Statistically significant increase occurred during 2014–2015.

** Statistically significant increase occurred during 2014–2015; statistically significant decrease occurred during 2015–2016. Movies were removed as an exposure source after 2014.

^†† Statistically significant decreases occurred during 2015–2016 and 2014–2016.

The figure above is a bar graph showing the percentage of U.S. middle and high school students exposed to e-cigarette advertisements through any source, retail stores, the Internet, television/movies, and newspapers and magazines 2014–2016.

Abbreviation: CI = confidence interval.
* Exposure to each e-cigarette advertisement source was assessed by the following questions: Retail Stores: “When you go to a convenience store, super market, or gas station, how often do you see ads or promotions for e-cigarettes?”; Internet: “When you are using the internet, how often do you see ads or promotions for e-cigarettes?”; Television (TV)/Movies: In 2014, Television/movie exposure was assessed by the question “When you watch TV or go to the movies, how often do you see ads or promotions for e-cigarettes?” In 2015–2016, only TV exposures were assessed: “When you watch TV, how often do you see ads or promotions for e-cigarettes?”; and Newspaper and Magazines: “When you read newspapers or magazines, how often do you see ads or promotions for e-cigarettes?” For all questions, response options included “Never, Rarely, Sometimes, Most of the time, or Always.” A “not applicable” (N/A) response was also included to capture respondents who did not use each advertising source. Respondents were categorized as “Exposed” if they reported seeing ads or promotions “sometimes,” “most of the time,” or “always.” Respondents were categorized as “Unexposed” if they reported seeing ads or promotions “never,” or “rarely.” Individuals who reported N/A were included in the analysis in the “Unexposed” group. A composite measure of any advertisement exposure (any source) is assessed based on exposure to retail, internet, television/movies, and print ad exposures.
^† Population estimates rounded down to the nearest 0.1 million.
^§ Significantly different from males at p<0.05 based on paired t-test.
^¶ Significantly different from non-Hispanic white at p<0.05 based on paired t-test.
** Significantly different from 6th grade at p<0.05 based on paired t-test.
^†† Significantly different from middle school at p<0.05 based on paired t-test.
^§§ Significantly different from noncurrent users at p<0.05 based on paired t-test.
^¶¶ Based on respondents’ use of cigarettes, cigars, smokeless tobacco (includes chewing tobacco/snuff/dip, snus, and dissolvable tobacco), hookah/waterpipe, regular pipe, and/or bidis on at least one day during the past 30 days.

FIGURE 2. Percentage of U.S. middle and high school students who were exposed to e-cigarette advertising, by number of exposure sources*— National Youth Tobacco Survey, United States, 2014–2016

* The four exposure sources were retail stores, the Internet, television/movies, and newspapers and magazines. Movies were removed as an advertising source after 2014.

The figure above is a bar graph showing the percentage of U.S. middle and high school students who were exposed to e-cigarette advertising, by number of exposure sources during 2014–2016.