Effects of branded health messages on e-cigarette attitudes, intentions, and behaviors: a longitudinal study among youth and young adults

Teen smoking of combustible cigarettes has declined since 2000, but the use of e-cigarettes, or vaping nicotine, has significantly increased in the past decade. The percentage of high school students who have ever tried e-cigarettes has increased from 4.5% in 2011 to 39.9% in 2020, and the percentage of high school students who used e-cigarettes in the past month has increased from 1.5% in 2011 to 19.6% in 2020 [1]. Of high school students who had currently used any tobacco product in 2020 (23.6%), the majority used e-cigarettes. Due to the high use of e-cigarettes among youth and young adults, the health risks of e-cigarette use are being heavily studied. There are early indications that e-cigarettes containing nicotine can harm the immune system, cause inhalation of carcinogenic substances, and negatively affect respiratory health [2‐4]. These negative health effects are a major cause for concern among youth and young adults.

E-cigarette companies have effectively promoted their branded products on digital media by leveraging social media influencers within social network communities focused on e-cigarettes [5], widely reaching youth and young adults, the primary users of digital media [6, 7]. These marketing strategies closely mimic those of early cigarette advertising to create a positive social norm for using e-cigarettes. JUUL’s “Vaporized” campaign presented a youth-forward brand image by depicting young models using e-cigarettes among colorful, eye-catching backgrounds and references to pop culture [8, 9]. “Vaporized” launched in 2015 and spread across digital platforms with the help of other pro-social network communities [8, 9].

In 2017, the national truth campaign leveraged their success with decreasing the rates of cigarette use among youth and young adults [10, 11] to combat the emerging e-cigarette trend using marketing efforts that directly counteract e-cigarette industry marketing practices. The truth-branded, anti-e-cigarette campaign is focused on changing social norms, which have partly made this behavior so popular. The continuity in brand marketing strategies is solidified in content presentation, arming a new generation of potential and current e-cigarette users with the facts they need to make decisions on product use. In order to reach the youth and young adult audience, the truth-branded counter-marketing messages are largely disseminated on digital media using many of the promotional strategies wielded by the tobacco industry, including social media influencers.

“Brand equity,” measured by a multi-dimensional scale, assesses the perceptions of a brand and the value of its product, service, or message [12, 13]. Years of social marketing research has shown that brand equity mediates positive attitudes toward [14] and performance of a desired behavior [15, 16]. For example, studies specific to truth’s campaigns have shown brand equity to be effective in reducing smoking among youth and young adults by mediating the effects of campaign exposure [17]. Studies indicated that positive brand equity, distinct from the content of the messages, functioned as a protective factor for those who had never smoked and reduced self-reported intentions to smoke and past 30-day smoking among ever and current smokers [18‐20].

While substantial evidence exists on the effectiveness of branding for the truth counter-marketing campaign for combustible cigarettes, the influence of branding has not yet been evaluated for its e-cigarette messaging strategies. This study builds upon the longitudinal analysis by Evans et al. (2017) [14] that found higher overall brand equity at baseline predicted less cigarette smoking and more positive anti-tobacco attitudes 1 y later, and that an increase in brand equity over time predicted more positive anti-tobacco attitudes 1 y later. The purpose of this study is to assess the role of anti-tobacco brand equity in influencing e-cigarette attitudes, intentions, and behaviors among youth and young adults over time. A longitudinal sample was utilized to examine change in brand equity over 1 y in relation to e-cigarette attitudes, intentions, and behavior 18 months after baseline.

Overall, participants’ mean age at baseline was 21 years (SD = 2.7), with the majority being female (59%), non-Hispanic white (64%), reporting “Living comfortably” or “Meet needs with a little left” (77% combined) and having some education at the college level or above (69%). Most participants had a parent with a college education or higher (61%). Among the entire study sample, the mean sensation seeking score was 3.0 (SD = 0.8, range 1–5). A total of N = 6427 participated in all three waves of data collection for this study: were aware of the truth brand in Spring 2018, responded to the truth brand items again in Spring 2019, and participated in the Fall 2019 data collection (Tables 1 and 2).

Table 3 presents the results of logistic regression models to examine the relationship between the full brand equity scale and each subscale at time one (Spring 2018) and e-cigarette attitudinal/behavioral outcomes 18 months later (Fall 2019). The brand equity constructs measured at time one were significantly associated with most of the outcomes 18 months later. The overall brand equity scale and all subscales in Spring 2018 (time one) were associated with higher anti-e-cigarette attitudes and lower odds of intention to use e-cigarettes in Fall 2019 (18 months later). Lower odds of the behavior, current use of e-cigarettes, in Fall 2019 were only associated with the full brand equity scale, brand loyalty, and brand awareness of tobacco, with all odds ratios less than 0.9.

Next, a change in brand equity from time one to time two on e-cigarette attitudinal and behavioral outcomes 18 months later was examined using logistic regression models (Tables 4-5). Table 4 reports the effects of change in overall brand equity on e-cigarette outcomes, whereas change in each brand equity subscale on the outcomes is seen in Table 5. Effects of covariates were similar in models shown in both tables; covariates are omitted in Table 5. Findings indicate that a one-point change in any brand equity subscale between Spring 2018 and Spring 2019 was significantly associated with 3–9% (β: 0.03–0.09, p < 0.001) greater anti-e-cigarette attitudes. In addition, a one-point change in the overall brand equity scale, popularity/leadership, and brand awareness of tobacco was significantly associated with approximately 21% (OR 0.79, CI 0.67–0.93, p < 0.05), 13% (OR 0.87, CI 0.76–0.99, p < 0.05), and 13% (OR 0.87, CI 0.78, 0.98, p < 0.05) lower odds of intention to use e-cigarettes respectively.

The truth campaign’s established brand, which was largely focused on preventing combustible cigarette smoking, has been shown to be associated with reduced smoking initiation and use [18, 20]. Previous studies have shown a longitudinal effect of brand equity on smoking outcomes in the context of other anti-tobacco campaigns [18]. This study investigated whether similar effects would be observed in anti-e-cigarette campaigns, building upon truth’s brand health momentum and providing evidence of the influence of the truth tobacco counter-marketing brand equity on e-cigarette use outcomes. Findings indicate that higher brand equity at baseline was significantly associated with greater anti-e-cigarette attitudes and lower odds of intention to use e-cigarettes over time. Significant effects of an increase in brand equity over time on subsequent anti-e-cigarette outcomes were identified. Specifically, a one-point change in the overall brand equity scale, and each of the individual subscales, was associated with an increase in anti-e-cigarette attitudes. Additionally, a one-point increase in the overall scale, and the leadership/popularity and tobacco brand awareness subscales, was associated with a decrease in intention to use e-cigarettes.

These findings are consistent with previous research [18] on the effects of brand equity on outcomes related to combustible use; brand equity continues to be a robust predictor of anti-e-cigarette campaign outcomes. Although the changes in brand equity observed in the study time period were relatively small in total magnitude, these changes were associated with improved anti-e-cigarette outcomes. Brand equity is not only a consistent predictor of improved outcomes over multiple studies, but it is also a highly sensitive measure. While the observed increase in brand equity over time was small, it produced a significant effect on anti-e-cigarette outcomes, indicating that brand equity is a sensitive scale. The truth campaign makes a great effort to remain relevant to our audience in order to maintain or increase brand equity. We did this in part between 2018 and 2019 by pivoting from focusing only on cigarette smoking to including prevention of e-cigarettes in our messaging. Successful efforts to further increase brand equity in truth may produce even greater prevention effects. This hypothesis should be explored in future research.

Future research needs to focus on brand equity scales specific to anti-e-cigarette outcomes, as the current study used the existing tobacco-focused brand equity scale. They should also examine these effects in the context of other anti-e-cigarette campaigns in addition to truth. Additionally, future studies should examine how and to what extent demographic and behavioral factors vary among individuals who have higher and lower levels of brand equity. Moreover, studies should examine the trajectories of brand equity increases over time to help elucidate the mechanisms by which the scale may indicate anti-e-cigarette behavior over time.

There were some limitations to the current study. First, we did not analyze data or compare the current data on tobacco brand awareness to an e-cigarette specific brand awareness subscale. E-cigarette use is a rapidly increasing phenomenon, especially among adolescents and young adults. It is also highly popular and perceptions of risk and personal harm from e-cigarettes differ from combustible use. Also, this study did not include the full address-based random sample, which could affect the results. However, we did not observe any evidence of bias in outcomes in the sub-sample used in this analysis. Lastly, this study is limited in that it cannot attribute causation. While we observed an association between brand equity and anti-e-cigarette attitudes, we cannot rule out reverse causation (i.e., prior attitudes leading to variation in brand equity).

Brand equity is a robust and highly sensitive construct for assessing how branded anti-e-cigarette messages can shift population-level attitudes, beliefs, and intentions. This research extends previous studies on anti-combustible branding and provides evidence that this counter-marketing strategy is effective in preventing e-cigarette use as well. Brands are powerful tools for public health interventions, especially in tobacco and nicotine control. National, state, and local public health education efforts can benefit by the use of branding, particularly for those aimed at youth and young adults.