Meghan E Morean1,2, Olivia A Wackowski3,4, Thomas Eissenberg5, Cristine D Delnevo3,4, Suchitra Krishnan-Sarin1, Ralitza Gueorguieva6. 1. Yale School of Medicine, Department of Psychiatry, New Haven, CT, USA. 2. Oberlin College, Department of Psychology, Oberlin, OH, USA. 3. Center for Tobacco Studies, Rutgers University, New Brunswick, NJ, USA. 4. Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, New Brunswick, NJ, USA. 5. Virginia Commonwealth University, Department of Psychology, Richmond, VA, USA. 6. Yale School of Public Health, Department of Biostatistics, New Haven, CT, USA.
Abstract
INTRODUCTION: E-cigarette liquid nicotine concentrations typically are labeled as mg/mL or percent, which poorly convey nicotine strength to users. We evaluated whether four novel nicotine concentration labels better convey information about nicotine strength and addictiveness. METHODS: Adolescents and young adults (N = 826) completed an online survey in 2020. Participants rated nicotine concentrations (3, 6, 18, 30, 40, and 50 mg/mL) from "no nicotine" to "very high nicotine" communicated using current market labels (mg/mL, percent) and four new labels (text-based, caution sign-shaped, horizonal stoplight, vertical thermometer) which used color, symbols, and verbal strength descriptors. Participants reported on perceived addictiveness for all labels viewed and rank-ordered labels on perceived ability to convey information accurately. RESULTS: Participants ranked the vertical (77%) and horizontal (70%) labels in first or second place and mg/mL (59.1%) and percent (47.2%) in last or second-to-last place. All new labels conveyed nicotine strength more accurately than did market labels (M[SD] correct of 6: percent = 1.50[1.08]; mg/mL = 2.14[1.52]; caution = 5.23[1.37]; vertical thermometer = 5.28[1.51]; text = 5.33[1.36]; horizontal stoplight = 5.47[1.14]), with the horizontal label also outperforming the thermometer and caution labels. Underestimating nicotine strength was uncommon among all new labels (4.7-6.8%). The new labels also were associated with increased perceived addictiveness at higher concentrations (30, 40, and 50 mg/mL), although the thermometer label underperformed the others. When considering perceived nicotine strength, rates of strength underestimates, perceived addictiveness, and rank ordering, the horizontal stoplight label performed best. CONCLUSIONS: Novel labeling could improve understanding of nicotine strength and e-cigarette-related risk. IMPLICATIONS: Extending prior research showing that adolescents and young adults who use Electronic Nicotine Delivery Systems (ENDS) have difficulty understanding nicotine concentrations labeled using mg/mL and percent nicotine, the current study demonstrates that novel nicotine concentration labels can improve understanding of nicotine strength and influence perceptions of addictiveness among young ENDS users. While four novel labels were tested, each outperforming current market labeling, the novel label that resembles a horizontal stoplight performed best. The study provides proof-of-concept that creating an easy-to-understand nicotine concentration label is possible and that new labeling better conveys information about nicotine strength and addictiveness.
INTRODUCTION: E-cigarette liquid nicotine concentrations typically are labeled as mg/mL or percent, which poorly convey nicotine strength to users. We evaluated whether four novel nicotine concentration labels better convey information about nicotine strength and addictiveness. METHODS: Adolescents and young adults (N = 826) completed an online survey in 2020. Participants rated nicotine concentrations (3, 6, 18, 30, 40, and 50 mg/mL) from "no nicotine" to "very high nicotine" communicated using current market labels (mg/mL, percent) and four new labels (text-based, caution sign-shaped, horizonal stoplight, vertical thermometer) which used color, symbols, and verbal strength descriptors. Participants reported on perceived addictiveness for all labels viewed and rank-ordered labels on perceived ability to convey information accurately. RESULTS: Participants ranked the vertical (77%) and horizontal (70%) labels in first or second place and mg/mL (59.1%) and percent (47.2%) in last or second-to-last place. All new labels conveyed nicotine strength more accurately than did market labels (M[SD] correct of 6: percent = 1.50[1.08]; mg/mL = 2.14[1.52]; caution = 5.23[1.37]; vertical thermometer = 5.28[1.51]; text = 5.33[1.36]; horizontal stoplight = 5.47[1.14]), with the horizontal label also outperforming the thermometer and caution labels. Underestimating nicotine strength was uncommon among all new labels (4.7-6.8%). The new labels also were associated with increased perceived addictiveness at higher concentrations (30, 40, and 50 mg/mL), although the thermometer label underperformed the others. When considering perceived nicotine strength, rates of strength underestimates, perceived addictiveness, and rank ordering, the horizontal stoplight label performed best. CONCLUSIONS: Novel labeling could improve understanding of nicotine strength and e-cigarette-related risk. IMPLICATIONS: Extending prior research showing that adolescents and young adults who use Electronic Nicotine Delivery Systems (ENDS) have difficulty understanding nicotine concentrations labeled using mg/mL and percent nicotine, the current study demonstrates that novel nicotine concentration labels can improve understanding of nicotine strength and influence perceptions of addictiveness among young ENDS users. While four novel labels were tested, each outperforming current market labeling, the novel label that resembles a horizontal stoplight performed best. The study provides proof-of-concept that creating an easy-to-understand nicotine concentration label is possible and that new labeling better conveys information about nicotine strength and addictiveness.
Authors: David Hammond; Geoffrey T Fong; Ron Borland; K Michael Cummings; Ann McNeill; Pete Driezen Journal: Am J Prev Med Date: 2007-03 Impact factor: 5.043
Authors: Jeffrey G Willett; Morgane Bennett; Elizabeth C Hair; Haijuan Xiao; Marisa S Greenberg; Emily Harvey; Jennifer Cantrell; Donna Vallone Journal: Tob Control Date: 2018-04-18 Impact factor: 7.552
Authors: Tory R Spindle; Alison B Breland; Nareg V Karaoghlanian; Alan L Shihadeh; Thomas Eissenberg Journal: Nicotine Tob Res Date: 2014-09-19 Impact factor: 4.244
Authors: Tory R Spindle; Marzena M Hiler; Megan E Cooke; Thomas Eissenberg; Kenneth S Kendler; Danielle M Dick Journal: Addict Behav Date: 2016-12-18 Impact factor: 3.913
Authors: Adam M Leventhal; David R Strong; Matthew G Kirkpatrick; Jennifer B Unger; Steve Sussman; Nathaniel R Riggs; Matthew D Stone; Rubin Khoddam; Jonathan M Samet; Janet Audrain-McGovern Journal: JAMA Date: 2015-08-18 Impact factor: 56.272
Authors: Mohamad Sleiman; Jennifer M Logue; V Nahuel Montesinos; Marion L Russell; Marta I Litter; Lara A Gundel; Hugo Destaillats Journal: Environ Sci Technol Date: 2016-07-27 Impact factor: 9.028
Authors: Meghan E Morean; Olivia A Wackowski; Thomas Eissenberg; Cristine D Delnevo; Suchitra Krishnan-Sarin Journal: Nicotine Tob Res Date: 2021-08-04 Impact factor: 5.825