Pack Modifications Influence Perceptions of Menthol E-cigarettes
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Pack Modifications Influence
Perceptions of Menthol E-cigarettes
Amy M. Cohn, PhD
Amanda L. Johnson, MHS
Haneen Abudayyeh, MPH
Bonnie King, MHS
Jess Wilhelm, PhD
Objectives: Tobacco package colors and descriptors influence attitudes and intentions to use. This
study examined the impact of flavor, color, and descriptors on electronic cigarette (e-cigarette)
packages young adults’ perceptions of e-cigarettes. Methods: We recruited 2872 US participants
ages 18-24 from Amazon Mechanical Turk (2018-2019) and randomized them to view one of 7
e-cigarette package images that varied by flavor (menthol vs tobacco), color (green or brown
vs black and white), and descriptor (present vs absent). Models examined main and interactive
effects of flavor, color, and descriptor on perceptions of appeal, harm, and addictiveness, and
the moderating effects of product appeal. Results: Menthol e-cigarette packages were rated as
more “attention grabbing,” “appetizing,” and “fun to use.” Perceptions of harm and addictiveness
did not vary across package conditions. Interactions of menthol pack conditions with appeal
emerged. Specifically, participants exposed to the green package with the menthol descriptor
reported low e-cigarette harm perceptions across all levels of “attention grabbing” and “discour-
ages use,” while those exposed to the green package without the menthol descriptor or the
brown package with the tobacco descriptor reported lower harm perceptions as ratings of prod-
uct appeal increased. Conclusions: Colors and descriptors on e-cigarette packaging influence
product appeal and harm perceptions.
Key words: flavored tobacco; menthol; e-cigarettes; young adults; perceived harm; perceived addictiveness; appeal;
packaging; marketing; tobacco companies
Tob Regul Sci.™ 2021;7(2):87-102
DOI: doi.org/10.18001/TRS.7.2.1
S
urveillance data show that the prevalence of bacco smoke or vapor, making it easier for new us-
current e-cigarette use has increased signifi- ers to initiate tobacco use. Flavors also have been
cantly among young adults ages 18-24,1 and posited to enhance the appeal and attractiveness
flavors are a prominent reason for use.2-6 E-ciga- of tobacco products because of their high reward
rettes are electronic or battery-powered devices that value and history of associations with candy and
heat liquid, usually containing nicotine, into aero- other food items.7 Experimentation with flavored
solized content that can be inhaled. Findings from tobacco products has been linked to progression
the PATH Study (2014-2015) show that 66.7% to regular tobacco use and nicotine dependence in
of past 30-day young adult e-cigarette users report youth and young adults.8-13
use of a flavored e-cigarette.5 Flavors have been The US Food and Drug Administration (FDA)
hypothesized to mask the harshness of inhaled to- issued regulatory action in January 2020 ban-
Amy M. Cohn, Associate Professor, Department of Pediatrics, TSET Health Promotion Research Center, Stephenson Cancer Center, University of
Oklahoma Health Sciences Center, Oklahoma City, OK, United States. Amanda L. Johnson, Senior Research Biostatistician, TSET Health Promo-
tion Research Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States. Haneen Abudayyeh, Researcher, Public
Health Center for Substance Use Research, Battelle Memorial Institute, Baltimore, MD, United States. Bonnie King, Research Project Manager, Pub-
lic Health Center for Substance Use Research, Battelle Memorial Institute, Baltimore, MD, United States. Jess Wilhelm, Principal Research Scientist
and Biostatistician, Public Health Center for Substance Use Research, Battelle Memorial Institute, Baltimore, MD, United States.
Correspondence Dr Cohn; amy-cohn@ouhsc.edu
Tob Regul Sci.™ 2021;7(2):87-102 87
Pack Modifications Influence Perceptions of Menthol E-cigarettes
ning cartridge-based flavored e-cigarettes, includ- tally examined whether modifying different aspects
ing fruit and mint flavors. However, menthol and of e-cigarette packaging (flavor, descriptor, color)
tobacco flavored e-cigarettes, both cartridge and influences perceptions of appeal, harm, and ad-
non-cartridge-based, remain available to consum- dictiveness, using a large sample of over 2800 US
ers. This is concerning because menthol is one of young adults. The first objective examined the
the top 3 most common e-cigarette flavors used by main and interactive effects of flavor type (men-
young adults.5 Published data suggest that sales of thol vs tobacco), package color (color vs black and
menthol e-cigarettes could increase following the white/B&W), and flavor descriptor (present or ab-
removal of fruit and candy-flavored e-cigarettes sent) on perceptions of e-cigarette appeal, harm,
from the market.14 Furthermore, many new dispos- and addictiveness. The second objective examined
able e-cigarette devices have entered the market to the associations between ratings of appeal with per-
provide flavors that have been banned in cartridge- ceptions of e-cigarette harm and addictiveness, and
based e-cigarettes. the moderating effect of appeal ratings on the as-
Packaging and marketing also influence the al- sociations of menthol packages with perceptions of
lure and perceived attractiveness of flavored to- e-cigarette harm and addictiveness. We specifically
bacco products.7,15,16 Tobacco companies have long recruited a general sample of young adults rather
manipulated the characteristics of tobacco prod- than a selected group defined by their tobacco use
ucts through packaging and marketing, targeted to status (eg, susceptible e-cigarette users, never e-cig-
specific vulnerable and at-risk sub-groups, includ- arette users) so that findings could be generalizable
ing young adult smokers and non-smokers who are to a larger audience of young adults, who may be
susceptible to use.17-20 Tobacco industry documents consumers of tobacco products in the future.
highlight that youth and young adult smokers are
especially curious about trying flavored products.16 METHODS
Younger individuals who have never used a tobacco Participants and Procedure
product are familiar with candy and fruit flavors Participants were recruited via Amazon Mechani-
and less likely to have experience with “tobacco” as cal Turk (AMT) between 2018 and 2019. Eligible
a flavor. Thus, images and descriptors on tobacco individuals were ages of 18 and 24, resided in the
product packaging that mimic or portray these ap- US, and reported a 95% approval rating on AMT.
pealing flavors (eg, cherry, chocolate) may increase AMT is a crowdsourcing platform that allows for
desire to use a tobacco product. Young people also rapid and cost-effective study recruitment.23,24
may be more likely to associate the characteriz- AMT workers are compensated for completing
ing flavor of “tobacco” with greater perceptions of small, discrete tasks, called “Human Intelligence
harm and addiction, given the widespread knowl- Tasks,” or HITs. Workers search the AMT website
edge about the deleterious health effects of ciga-
for a HIT, which can be pre-viewed before starting
rette smoking.21 This may make tobacco-flavored a task.25,26 This study was completed online.
products less appealing.
After completing a brief eligibility screen and
Certain descriptors on tobacco packaging and providing consent, 2879 participants were ran-
advertisements, such as “light,” “mild,” and “low,” domized to view one of 7 different images of an e-
have been found to mislead consumers into think- cigarette package in which flavor type (menthol vs
ing that the product is less harmful than other to- tobacco), presence or absence of a flavor descriptor,
bacco products.22 As a result, several descriptors and color were manipulated. One of the conditions
were banned under the 2009 Family Smoking was a “control condition” that had no flavor de-
Prevention and Tobacco Control Act (FSPTCA). scriptor and black and white color on the package.
However, flavor descriptors on cigarettes and other Twenty participants completed the survey in less
tobacco products have not been banned. Few data than 120 seconds and were removed from all analy-
exist on the ways in which young adult appeal for ses in an effort to control for inattentiveness to the
flavored e-cigarettes is influenced by packaging, task, leaving a total sample of 2859 participants in
a product characteristic that can be regulated by the analysis.
FDA. To address this gap, this study experimen-
The 7 package conditions are described as follows
88
Cohn et al
Figure 1
Experimental Stimuli by Study Condition
No Descriptor “Classic Tobacco” “Magnificent Menthol”
Black and
Package A Package F Package C
White
(B&W)
Brown Color
Package G Package E
Green Color Package D Package B
Tob Regul Sci.™ 2021;7(2):87-102 DOI: doi.org/10.18001/TRS.7.2.1 89
Pack Modifications Influence Perceptions of Menthol E-cigarettes
(Figure 1): (1) control condition (black and white, ever (not current), and past 30-day cigarette and
no descriptor); (2) green e-cigarette package with e-cigarette use, as well as ever and past 30-day use
menthol descriptor (“Magnificent Menthol”); (3) of menthol flavored e-cigarettes.
black and white (B&W) e-cigarette package with Perceived absolute addictiveness. After viewing
menthol descriptor; (4) green e-cigarette package the randomized package image, participants were
without menthol descriptor; (5) brown e-cigarette asked: “How addictive do you think e-cigarettes are
package with tobacco descriptor (“Classic Tobac- to health?” (1 = not at all addictive to 5 = extremely
co”); (6) B&W e-cigarette package with tobacco addictive).
descriptor; and (7) brown e-cigarette package with- Perceived absolute harmfulness. Participants
out tobacco descriptor. We used the Blu e-cigarette were asked: “How harmful do you think e-ciga-
brand given its high level of familiarity and pop- rettes are to health?” (1 = not at all harmful to 5=
ularity at the time the study was conceptualized extremely harmful).
and funded (2017).28 Menthol was selected given Package appeal. After viewing the randomized
its high policy relevance and popularity in young package image, participants were asked about 8 dif-
adults.29-37 For the color conditions, the brown ferent dimensions of package appeal, with the fol-
packaging was designed to mimic the brown color lowing item stem: “Now, thinking about the image
of a tobacco leaf and the green packaging was de- you just saw of an e-cigarette, how much do you
signed to mimic the green color of a mint leaf. Fla- agree or disagree with the following”… with the
vor descriptor conditions included text related to following responses (1) the packaging grasped my
flavor as well as an associated image. Images that attention (“attention grabbing”); (2) the packag-
were shown were from photographs taken of the ing was appealing (“appealing”); (3) the packaging
product by project staff and modified by the mar- made the product appear appetizing, like it would
keting team at the awarding institution. taste good (“taste good/appetizing”); (4) the packag-
Prior to viewing package images, participants ing suggested this product would be fun to vape/
provided information on demographics and tobac- use(“fun to vape”); (5) the packaging put thoughts in
co use behavior. After viewing the assigned pack- my mind about not wanting to vape/use the product
age image, participants answered questions about (“discourages use”); (6) the packaging gave me good
perceived addictiveness, harm, and 8 dimensions of reason to vape/use the product(“encourages use”);
appeal of the product image they had just viewed. (7) after seeing this packaging, I would consider try-
Surveys took approximately 7 minutes to complete ing one(“intention to try”); and (8) after this pack-
and participants were compensated $1. age, my friends would be interested in trying one
(“friends would try”). Response options ranged from
Measures 1 = strongly disagree to 7 = strongly agree. Higher
The measures used in this study were adapted scores indicate greater appeal for all items except for
from items in the PATH study.53 These measures “discourages use,” where higher scores indicate lower
are also similar to those used in a study published appeal (eg, lower intentions to use).
by our team.49
Demographic information. We collected infor- Data Analysis
mation on sex, race (white, black, other), ethnic- We first examined demographic and tobacco use
ity (Hispanic, non-Hispanic), education (< high factors of the sample, and equivalence across study
school, high school/GED/vocational training, conditions on these factors to ensure randomiza-
some college or greater), and income (< $20,000; tion was complete. Next, we examined main effects
20,000-$35,000; $35,001-$50,000; $50,001- of ever e-cigarette use and ever use of menthol e-
$75,000; > $75,000). cigarettes on ratings of appeal, harmfulness, and
Tobacco use. Participants were asked about ever, addictiveness. Ever e-cigarette users were comprised
past year, and past 30-day use of cigarettes and e- of current users as well as those who had ever tried
cigarettes, as well as ever and past 30-day menthol an e-cigarette in their lifetime.
flavored use of e-cigarettes. Variables were created For objective one, analysis of covariance (AN-
reflecting mutually exclusive categories of never, COVA) tests were used to compare main effects
90Cohn et al
of e-cigarette flavor (any menthol package versus tiveness, at different levels of appeal (moderator).
any tobacco package), package color (any color Comparison 2 examined differences between pack-
package versus any B&W package), and descriptor age B versus package D (the green package without
(any package with a descriptor versus any package the menthol) on perceived harm and addictiveness,
without a descriptor) on perceived harm, addictive- at different levels of appeal (moderator). Com-
ness, and the 8 indices of appeal. To do this, 3 new parison 3 examined differences between package
variables were created. A new variable capturing B versus package E (the brown package with the
menthol packaging was created by coding menthol tobacco descriptor) on perceived harm and addic-
packages B, C, and D (Figure 1) as “1” and coding tiveness, at different levels of appeal (moderator).
tobacco packages E, F, G as “0”. A new variable cap- In all comparisons, package B was coded as 1 and
turing color packaging was created by coding pack- the comparison package was coded as 0. Following
ages B, D, E, and G (Figure 1) as “1”, and all other recommendations of Aiken and West,38 using the
packages were coded as “0.” Lastly, a new variable relevant package comparison as the independent
capturing packages with a descriptor was created variable (eg, comparison 1) and the relevant item
by coding packages B, D, D, and F as “1” and all of appeal as the moderator (eg, “fun to use/vape”),
other package images as “0.” The control condition separate regression equations were computed by
(package A) with no color and no descriptor was entering ever e-cigarette use in the first step, main
categorized as “0” for both the color condition vari- effects of package comparison and appeal in the
able and the descriptor condition variable. To take second step, and the interaction of package com-
a conservative analytic approach, models controlled parison X appeal in the third step. For equations
for “ever use” of e-cigarettes (yes = 1; 0 = no), be- with significant interactions, regression coefficients
cause prior e-cigarette use may impact product per- for simple effects were examined.38 Unstandardized
ceptions. This also aligned with published research betas are reported. All analyses were conducted
using a nearly identical experimental manipula- with SPSS 26. For Bonferroni adjustments, SPSS
tion,49 but with little cigars/cigarillos. multiplies the p-value of the least significant differ-
To determine interactive effects, ANCOVA tests ences by the number of tests, and produces a new
were conducted to examine pairwise comparisons p-value. Thus, the p-value presented in the tables is
across each of the 7 conditions on the outcomes an adjusted p-value. Analyses used listwise deletion.
of interest, with Bonferroni adjusted pairwise com-
parisons. All models controlled for “ever use” of RESULTS
e-cigarettes. Sample Characteristics
For objective 2, linear regression models were The sample was primarily male (55.8%) and
used to examine main and interactive effects of white (72.2%); 16.7% reported Hispanic ethnic-
specific menthol packaging and ratings of appeal ity (Table 1). The mean age of respondents was
on the outcomes of perceived harm and addictive- 21.37 years (SD = 1.98). For tobacco use histo-
ness. All models controlled for “ever use” of e-ciga- ry, 57.7% reported past 30-day cigarette use and
rettes. To reduce the number of regression models 31.6% reported past 30-day e-cigarette use. Nearly
that were conducted, and thus, the Type 1 error three-fourths of e-cigarette users had ever used a
rate, appeal items that were statistically significant menthol flavored e-cigarette. The study conditions
in the previous Bonferroni adjusted simple effects were about equally distributed in terms of sample
analyses were examined as moderators; these were size (see Table 2 for sample size per condition), and
“attention grabbing,” “taste good/appetizing,” “fun there were no statistically significant differences
to use/vape,” and “discourages use.” In models test- across study conditions on demographic or tobacco
ing for interactions, 3 specific menthol package use factors.
comparisons were examined in separate regression
models. Comparison 1 examined differences be-
tween package B (green package with menthol de- Main Effects of Ever E-cigarette Use and Ever
scriptor) versus package C (B&W package with the Use of Menthol E-cigarettes
menthol descriptor) on perceived harm and addic- There were statistically significant main effects of
ever use of e-cigarettes on perceptions of harm, ad-
Tob Regul Sci.™ 2021;7(2):87-102 DOI: doi.org/10.18001/TRS.7.2.1 91Pack Modifications Influence Perceptions of Menthol E-cigarettes
Table 1
Demographic and Tobacco Use Characteristics of the Sample of Young Adults (N = 2859)
Mean Standard Deviation
DEMOGRAPHICS
Age 21.4 1.98
% N
Sex
Male 55.8 1594
Female 44.2 1265
Race
White 72.2 2060
Black/African-American 11.4 327
Asian 8.0 230
Other 8.4 241
Ethnicity
Hispanic 16.7 478
Non-Hispanic 83.3 2381
Income
< $20,000 17.8 509
$20,000-$35,000 23.8 680
$35,001-$50,000 19.2 549
$50,001-$75,000 19.7 562
> $75,000 16.2 462
Prefer not to say 3.3 95
Education
< High school degree 2.2 62
High school
30.8 881
degree/GED/vocational training
Some college education or higher 67.0 1916
TOBACCO USE BEHAVIOR
Cigarette use
Never 21.1 604
Ever (not past 30-day) 21.1 604
Past 30-day 57.7 1651
E-cigarette use
Never 45.0 1287
Ever (not past 30-day) 23.3 668
Past 30-day 31.6 904
Menthol e-cigarette use a
Never 26.1 411
Ever 73.9 1161
Note.
a
Among ever e-cigarette users. Never, ever, and past 30-day use are mutually exclusive categories.
92Cohn et al
Table 2
Main Effects of E-cigarette Menthol Flavoring, Package Color, and Presence of a Flavor Descriptor
on Perceptions of E-cigarette Product Harm, Addictiveness, and Appeala
Flavor Color Descriptor
Black & No
Menthol Tobacco Color Descriptor
White Descriptor
N = 1229 N = 1221 N = 1634 N = 1634
N = 1225 N = 1224
M (SD) M (SD) p M (SD) M (SD) p M (SD) M (SD) p
Harm 3.21 (1.0) 3.21 (1.1) .67 3.22 (1.0) 3.18 (1.05) .44 3.19 (1.0) 3.22 (1.0) .53
Addictiveness 3.53 (1.1) 3.47 (1.3) .19 3.50 (1.1) 3.50 (1.1) .99 3.51 (1.1) 3.45 (1.1) .18
Appeal
Attention grabbing 4.39 (1.6) 4.24 (1.7) .03 4.39 (1.7) 4.18 (1.7) .001 4.30 (1.7) 4.30 (1.7) .91
Appealing 4.52 (1.6) 4.39 (1.7) .07 4.49 (1.7) 4.42 (1.7) .25 4.48 (1.6) 4.43 (1.7) .46
Taste good 4.31 (1.7) 4.10 (1.8) .005 4.25 (1.8) 4.08 (1.7) .01 4.24 (1.7) 4.09 (1.8) .04
Fun to vape 4.22 (1.7) 4.03 (1.7) .007 4.16 (1.7) 4.06 (1.8) .12 4.14 (1.7) 4.08 (1.8) .39
Discourages Useb 3.28 (1.8) 3.40 (1.8) .10 3.31 (1.8) 3.40 (1.8) .14 3.36 (1.8) 3.34 (1.8) .74
Encourages Use 3.60 (1.7) 3.51 (1.7) .22 3.56 (1.7) 3.55 (1.7) .88 3.58 (1.7) 3.52 (1.7) .36
Intention to try 3.65 (1.9) 3.55 (1.9) .27 3.59 (1.9) 3.62 (1.9) .82 3.62 (1.9) 3.59 (1.9) .84
Friends would try 4.04 (1.8) 3.91 (1.8) .10 3.99 (1.8) 3.99 (1.8) .96 4.00 (1.8) 3.97 (1.8) .69
Note.
All models control for ever use of e-cigarettes. Unadjusted means and standard deviations are reported. The p-values
from adjusted models are reported. F-values and degrees of freedom are presented in the text. Items in bold are signifi-
cantly different.
a
Menthol flavor condition was coded as “1” for the following images: the green menthol package with the menthol
descriptor (package B), the green menthol package without the menthol descriptor (package D), and the black and white
(B&W) menthol package with the menthol descriptor (package C); menthol flavor condition was coded as “0” for the
following images: the brown tobacco package with the tobacco descriptor (package E), the brown tobacco package
without the tobacco descriptor (package G), and the B&W tobacco package with the tobacco descriptor (package F).
Color condition was coded as “1” for the following images: the green menthol package with the menthol descriptor
(package B), the green menthol package without the menthol descriptor (package B), the brown tobacco package with
the tobacco descriptor (package E), and the brown tobacco package without the tobacco descriptor (package G); all
other packs were coded as “0”. Descriptor condition was coded as “1” for the following images: the green menthol
package with the menthol descriptor (package B), the B&W menthol package with the menthol descriptor (package C),
the brown tobacco package with the tobacco descriptor (package E), or the B&W tobacco package with the tobacco
descriptor (package F); all other images were coded as “0”. The control package with no flavor and no descriptor
(package A) was coded as “0” for both the color and descriptor conditions.
b
Higher scores indicate lower appeal (eg, lower intentions to use); for all other indices of appeal, higher scores indicate
greater appeal.
dictiveness, and all indices of appeal (all ps < .05). fects of ever menthol e-cigarette use on perceptions
Specifically, compared to never e-cigarette users, of harm, and several indices of appeal (“taste good/
ever e-cigarette users reported lower perceptions of appetizing,” “fun to use,” “encourages use,” “inten-
e-cigarette harm and addictiveness, and rated e-cig- tions to try,” and “friends would try”) (all ps < .05).
arette packages as more appealing (Supplemental Supplemental Table 1 (S1) shows the mean differ-
Table S1). ences between ever (vs never) e-cigarette users and
There were also statistically significant main ef- menthol (vs non-menthol) e-cigarette users.
Tob Regul Sci.™ 2021;7(2):87-102 DOI: doi.org/10.18001/TRS.7.2.1 93Pack Modifications Influence Perceptions of Menthol E-cigarettes
Main Effects of Flavor Type, Package Color, tobacco descriptor; p = .032). Lastly, package B
and Package Descriptor received lower ratings on “discourages use” com-
Table 2 shows ANCOVA results of the main pared to both package C (the B&W package with
effects of flavor condition (menthol vs tobacco), the menthol descriptor; p = .013) and package E
package color (color vs B&W), and flavor descrip- (the brown package with the tobacco descriptor; p
tor (present vs absent) on perceptions of e-cigarette = .015). No other significant differences between
harm, addictiveness, and package appeal, control- conditions were found.
ling for “ever use” of e-cigarettes. There were sta- Interaction of menthol package conditions and
tistically significant main effects of menthol (vs ratings of appeal on perceptions of harm and
tobacco) packages on several indices of appeal: addictiveness. After controlling for “ever use” of
“attention-grabbing” [F(1, 2433) = 4.61, p = .03], e-cigarettes, regression analyses revealed signifi-
“taste good/appetizing” [F(1, 2433 = 7.99, p = cant differences in e-cigarette harm perceptions
.005], and “fun to use” [F(1, 2433) = 7.20, p = between those who viewed package B (the green
.007), where menthol packages were rated as sig- package with the menthol descriptor) versus those
nificantly more appealing than tobacco packages who viewed package C (the green package without
on these indices. the menthol descriptor), as a function of different
There were also statistically significant main ef- ratings of “attention-grabbing” (interaction effect:
fects of package color (versus B&W) on “attention b = .09, p = .04). Specifically, Figure 2 shows that
grabbing” (F(1, 2841) = 10.73, p = .001) and “taste participants exposed to package B showed low e-
good/appetizing” [F(1, 2841 = 6.31, p = .012], cigarette harm perceptions across low and high rat-
where packages in color were rated as significantly ings of “attention grabbing” (b = .000, p =.992),
more appealing than packages in B&W (see Table while those exposed to the green package without
2 for mean differences). the menthol descriptor reported lower harm per-
There was a statistically significant main effect of ceptions at higher ratings of “attention-grabbing”
descriptor (versus no descriptor) on “taste good/ (b = -.09, p = .004). Thus, ratings of e-cigarette
appetizing” [F(1, 2841 = 4.34, p = .037], where harm remained the same across low versus high
packages with a flavor descriptor were perceived as ratings of product appeal (“attention grabbing”)
significantly more appetizing than packages with- among those exposed to the green package with
out a descriptor. No other statistically significant the menthol descriptor; while ratings of package
main effects emerged. appeal appeared to have an impact at reducing
risk perceptions when individuals view the green
e-cigarette package where the menthol descriptor
Simple Effects Comparisons of Flavor Type, was missing.
Package Color, and Package Descriptor
Similar to the analyses above, after controlling
Table 3 shows mean differences between pack for “ever use” of e-cigarettes, regression analyses
conditions on perceptions of e-cigarette harm, ad- revealed significant differences in e-cigarette harm
dictiveness, and package appeal, and results of sim- perceptions between those who viewed package B
ple effects comparisons of flavor type, color, and and those who viewed package E (the brown pack-
descriptor controlling for “ever use” of e-cigarettes. age with the tobacco descriptor), as a function of
Bonferroni-adjusted ANCOVA results revealed different ratings of “discourages use” (interaction
significant differences between package B (the effect: b = -.08, p = .04). Figure 3 shows that partic-
green package with the menthol descriptor) and ipants exposed to package B endorsed consistently
package F (the B&W package with the tobacco low ratings of e-cigarette harm perceptions across
descriptor), where package B was rated as signifi- low and high ratings of product appeal (b = .01, p
cantly more appealing on “attention-grabbing” (p = .980), while participants exposed to the brown
= .006), “taste good/appetizing” (p = .001), and package with the tobacco descriptor reported lower
“fun to use/vape” (p = .005). Further, package B harm perceptions at lower ratings of “discourages
was rated as significantly more appealing on “taste use” (b = .08, p = .004). Thus, ratings of e-cigarette
good/appetizing” compared to the control package harm remained the same across ratings of low ver-
(p = .001) and package G (brown package with no
94Table 3
Simple Effects Comparisons of Flavor, Package Color, and Package Descriptor on Perceptions of
E-cigarette Product Harm, Addictiveness, and Appeal
Condition
Control Menthol E-cigarette Package Images Tobacco E-cigarette Package Images
A– B– C– D– E– F– G–
B&W, Green, B&W, Green, Brown, B&W, Brown,
Tob Regul Sci.™ 2021;7(2):87-102
No Menthol Menthol No Menthol Tobacco Tobacco No Tobacco
Descriptor Descriptor Descriptor Descriptor Descriptor Descriptor Descriptor
(N = 409) (N =411) (N = 408) (N =410) (N = 408) (N = 408) (N = 405)
Statistically significant
pairwise comparisons M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)
(p-values)a
Perceived Harm NS
Perceived Addictiveness NS
Appeal
Attention grabbing B vs. F (.006) 4.50 (1.6) 4.08 (1.7)
Appealing NS
B vs. A (.001),
Taste good/appetizing B vs. F (.001), 4.00 (1.8) 4.50 (1.7) 3.99 (1.8) 4.12 (1.8)
B vs. G (.032)
Fun to vape B vs. F (.005) 4.36 (1.7) 3.91 (1.7)
B vs. C (.013),
Discourages Useb 3.10 (1.8) 3.51 (1.8) 3.52 (1.8)
B vs. E (.015)
Encourages Use NS
DOI: doi.org/10.18001/TRS.7.2.1
Intention to try NS
Friends would try NS
Note.
a
Only statistically significant Bonferroni adjusted p-values are reported. Unadjusted means and standard deviations are reported. All other pairwise
comparisons were not statistically significant.
b
Higher scores indicate lower appeal (eg. lower intention/desire to use); for all other indices of appeal, higher scores indicate greater appeal.
95
Cohn et alPack Modifications Influence Perceptions of Menthol E-cigarettes
Figure 2
Effects of Exposure to Menthol E-cigarette Package Images (with and without the
menthol flavor descriptor) and Ratings of Product Appeal (“attention grabbing”) on
E-cigarette Harm Perceptions
3.8
3.7
E-cigarette harm perceptions
b = -.09, p = .004
3.6
3.5
3.4
b = .000, p = .992
3.3
3.2
Menthol flavor, green color, no menthol descriptor
3.1
Menthol flavor, green color, with menthol descriptor
3
Low Attention grabbing High Attention grabbing
sus product appeal (eg, “discouraged use) among less likely to discourage use) appeared to decrease
those exposed to the green package with the men- risk perceptions among those who viewed a tradi-
thol descriptor; while ratings of package appeal (eg, tional tobacco e-cigarette package.
Figure 3
Effects of Exposure to Menthol and Tobacco Flavored E-cigarette Package Images
and Ratings of Product Appeal (“discourages use”) on E-cigarette Harm Perceptions
3.8
E-cigarette harm perceptions
3.7
3.6
b = .08, p = .04
3.5
3.4
3.3 b = .01, p = .980
3.2
Tobacco flavor, brown color, with tobacco descriptor
3.1 Menthol flavor, green color, with menthol descriptor
3
Low Discourages Use High Discourages Use
96Cohn et al
Other Main Effect and Interaction Models io, as certain menthol e-cigarettes are still available
Regression models revealed significant main ef- on the market. Consistent with our expectations,
fects of appeal ratings on perceptions of e-cigarette this “real world” menthol e-cigarette package was
harm and addictiveness (all ps < .01), such that rated as more appealing than the “real world” to-
greater product appeal was associated with lower bacco e-cigarette package (eg, in color, with the
perceptions of e-cigarette harm and addictiveness. descriptor) on multiple dimensions of appeal –
There was only one exception in which “discour- “attention grabbing,” “taste good/appetizing,” and
ages use” was unrelated to perceptions of addictive- “fun to use/vape.” Whereas the FDA does have the
ness (Supplemental Table 2 [S2]). authority to institute plain packaging or ban the
All models were re-examined with ever e-cigarette use of flavor descriptors, as these actions fit under
use and ever menthol e-cigarette use as modera- the domain of marketing and label regulation, the
tors, but no significant interaction were found. We FDA would need to propose a rule, support this
conducted ANCOVAs comparing green packages rule with scientific evidence, and likely defend its
(packages B and C; coded as 1) to brown packages decision in the courts. Our study findings support
only (packages E and G; coded as 0) on perceived the notion that some aspects of tobacco product
harm, addictiveness, and ratings of appeal. There packaging (colors and descriptors) contribute to
were no significant differences on any of the out- increased attraction to flavored products and pro-
comes. Furthermore, there were no significant in- vide some empirical support to the FDA in this
teractions of green versus brown packages with any respect. Individuals exposed to packages in color
indices of appeal (moderators) on perceived harm (compared to those in B&W), and packages with
and addictiveness. a descriptor (compared to those without a descrip-
tor) did not report lower perceptions of harm and
addictiveness, but did report greater product ap-
Discussion peal on several indices (“attention grabbing,” “taste
Our study revealed several important findings good/appetizing”).
about the effects of e-cigarette package modifica- For objective 2, main effects showed that higher
tions on perceptions of product appeal, e-cigarette product appeal overall was associated with lower
harm, and addictiveness. Consistent with previous- perceptions of harm and addictiveness, even after
ly published literature,39,40 young adults who had controlling for e-cigarette use history. Furthermore,
ever used an e-cigarette reported lower perceptions ratings of post-exposure product appeal influenced
of e-cigarette harm and addictiveness, and higher (moderated) differences between certain menthol
ratings of e-cigarette product appeal compared to packages with respect to post-exposure assessment
never users, regardless of which package image they of harm perceptions and addictiveness. Overall, in-
were randomized to view. For objective one, main teraction analyses showed participants randomized
effect analyses showed that any package that was to view the green package with the menthol descrip-
intended to depict a menthol e-cigarette (regard- tor (package B) indicated consistently low levels of
less of the presence/absence of a flavor descriptor e-cigarette risk at any level of product appeal. Thus,
or package color) was perceived as more attention- product appeal did little to influence these respon-
grabbing, appetizing, and fun to use compared to dents’ perceptions of the e-cigarette product they
any package that was intended to depict a tobacco had just viewed. This might be because this pack-
flavored e-cigarette. Furthermore, simple effects age condition had higher appeal ratings, in general,
analyses showed that the green package with the on “attention grabbing,” “taste good/appetizing,”
menthol descriptor (package B) was rated higher “fun to use/vape,” and lower ratings on “discourages
on “attention grabbing,” “taste good/appetizing,” use” compared to a number of other package condi-
and “fun to use/vape” and lower on “discourages tions, as evidenced by the simple effects analyses. In
use” compared to several other packages, even after contrast, perceptions of e-cigarette harm decreased
controlling for differences in e-cigarette use history. significantly as ratings of appeal increased, specifi-
It is worth noting that the green menthol package cally among participants who viewed the brown
with the mint/menthol leaf descriptor aligns with tobacco package with the descriptor or the green
the current “real world” e-cigarette market scenar- menthol package without the menthol descriptor.
Tob Regul Sci.™ 2021;7(2):87-102 DOI: doi.org/10.18001/TRS.7.2.1 97Pack Modifications Influence Perceptions of Menthol E-cigarettes Thus, higher ratings of package appeal appeared sible that a single exposure, rather than multiple to influence lower risk perceptions, but only when exposures over time (such as at the point of sale), participants viewed the e-cigarette package with- has little impact on changing behavior, but does out the menthol descriptor, or the brown tobacco change attitudes in the interim. package with the tobacco descriptor. This further There are several reasons to explain our results. highlights the potentially detrimental combination First, although exposure to different packs did not of menthol flavoring, package color, and the pres- appear to directly impact harm perceptions or in- ence of a menthol flavor descriptor young people’s tentions to use, they did appear to lead to greater perceptions of tobacco product risk. product appeal, and higher product appeal was Whereas the main effects results broadly compare found to be associated with perceptions that are e- differences across a variety of package conditions, cigarettes are less harmful and less addictive. This the Bonferroni-adjusted simple effects compari- is consistent with published work, showing that e- sons specifically examined differences comparing cigarette users are more receptive to marketing and across each individual study condition (rather than this receptivity is related to lower e-cigarette harm across combined conditions). Thus, results from perceptions, which in turn predict use behavior.39 the main effects of package flavor, for example, tell This is particularly alarming as recent data show us information, globally, about the potential im- that sales of JUUL menthol flavored e-cigarette pact of menthol flavoring on e-cigarette product products have increased after JUUL limited its sales perceptions, while results from the pairwise com- of fruit and candy flavors.14 Second, prior research parisons provide greater granularity about which also suggests that menthol cigarettes are popu- specific package characteristics (flavor, color, and lar among young adults because the cooling and descriptor) appear to influence these perceptions. “throat soothing” properties mask the harshness of Although we did not find differences between green inhaled tobacco smoke.41 This notion may extend and brown colored packs, we did find that color, to e-cigarettes and may explain why some menthol overall, did have some impact at increasing product packages were perceived as more appealing. Third, appeal. Such information provides supporting evi- given the widespread use of tobacco marketing tar- dence to the FDA if it moves forward with stricter geting young adults,16,42 it is possible this age group regulations of the marketing of tobacco products to associates the green color of an e-cigarette pack- reduce their appeal to younger individuals. age with a mint/menthol flavored tobacco product Overall, our study findings showed that menthol – much as they would with a Newport menthol e-cigarette packages were rated higher on several cigarette.52 Young adults may also associate the im- domains of product appeal (3 out of 8). Discrete age of a mint leaf with a menthol flavored product, choice experiments (DCEs) testing the influence even without having had prior e-cigarette use expe- of e-cigarette products characteristics (eg, flavor, rience. It is possible that product appeal mediates warning labels) on choice behavior and intentions the association between package exposure and atti- to use have found similar results.54-56 In a DCE tudes about e-cigarette-related harm. Longitudinal that examined the impact of varying attributes of studies examining causal links between exposure, e-cigarettes, including flavors, on adolescents’ in- appeal, and perceptions of e-cigarette harm would tentions to use e-cigarettes, Shang et al54 found that need to be conducted to make this determination. flavors had the most pronounced impact at increas- According to the Tobacco Control Act, tobacco ing the probability of choosing e-cigarettes among packaging that is misleading to consumers in mate- both “never users” and “ever users.” In our study, rial ways directly violates the Tobacco Control Act even though some young adults may have rated [ Sec. 903(a)(1) and (7)], even if there is no intent certain e-cigarette packages as more appealing, by the manufacturer to do so. Consequently, results they did not seem to feel more motivated to try from this study could provide support for the FDA these products. This might be acceptable for public to take enforcement actions against some flavored health if lower product appeal reduces intentions tobacco product marketing techniques in the US to use in the future; however, this would need to in attempts to reduce product appeal. In our study, be measured in longitudinal studies. It is also pos- exposure to certain menthol e-cigarette package im- 98
Cohn et al
ages did appear to lead to greater product appeal, investigation about attitudes about tobacco prod-
which in turn was correlated with lower perceptions ucts. Other tobacco-related studies conducted on
of e-cigarette harm and addictiveness. In addition, this platform report similarly high rates of tobacco
whereas menthol in cigarettes and e-cigarettes has use and cigarette smoking.46,49,50 Third, we did not
not been banned at the federal level, states and lo- examine effects of package modifications on per-
calities have the ability to restrict the time, place, ceptions of JUUL, which has risen significantly in
and manner of flavored tobacco product sales. By popularity in this age group. Fourth, we did not
focusing on whether menthol flavored tobacco test a wide of variety of e-cigarette flavor profiles,
product packaging misleads consumers into be- beyond menthol. Fifth, all models adjusted for dif-
lieving that these products are more appealing and ferences between e-cigarette users and non-users.
less harmful than traditional tobacco flavored ver- Thus, statistically significant associations between
sions of these products, the findings from this study study conditions and the outcomes of interest
add an important new dimension to the available were observed beyond these individual differences.
research about the abuse liability associated with However, although the use of ANCOVA and re-
menthol flavoring and inform policy changes to gression analyses provide some benefits in control-
protect public health. Additionally, because there ling for confounding factors, such as e-cigarette
were statistically significant main effects of package use, this technique has its limitations and cannot
color and package descriptors on some indices of be assumed to provide complete adjustment. Last-
appeal, the FDA or local jurisdictions may want to ly, we did not control for individual differences in
consider further restrictions on these marketing fac- perceptions of e-cigarette harm and addictiveness
tors, in an effort to reduce young consumer appeal prior to randomization. Given the relatively short
to use tobacco products. Previous research shows duration of the experiment (5-7 minutes), we were
that cigarette pack colors and imagery can impact concerned that pre-randomization assessment of
consumer perceptions,54,57,58 and that plain packag- these factors could influence post-randomization
ing can reduce product appeal.59 Lastly, our findings ratings.
have implications of our findings for Pre-Market
Tobacco Product Applications (PMTA), which Implications for Tobacco Regulation
are now required for e-cigarettes to remain on the There is a need to understand the impact of to-
market. Companies will have to show evidence that bacco product descriptors on tobacco-related harm
the introduction of their e-cigarette product could perceptions and behaviors given the rapidly chang-
“benefit public health,” and will have to include in- ing tobacco market and policy landscape. Findings
formation about possible negative impacts to popu- from this study could inform the development of
lation health, such as appeal to young people. Our new policies to reduce the public health impact
results suggest that some characteristics, like flavor
of tobacco use or the appeal of tobacco products
and color on e-cigarette packaging impact measures through marketing.16,51 Stricter regulation of e-
of appeal among young people. cigarette packaging may be one method to reduce
Study results should be interpreted in light of e-cigarette appeal among this vulnerable age group
several limitations. First, this study did not use and thus the prevalence and public health of to-
a nationally-representative sample. One demo- bacco use.
graphic analysis of AMT workers suggests that the
population is predominantly non-Hispanic white
and approximates the representativeness of the US Human Subjects Approval Statement
population.27 We chose AMT as our platform for The study methods and procedures were ap-
data collection because it allows for rapid and cost- proved by the Institutional Review Board of the
effective data collection on a discrete task. AMT Battelle Memorial Institute.
tasks are increasingly used in public health and
addiction research, including for tobacco use, and Conflict of Interest Disclosure Statement
have been widely validated.27,43-49 Second, it is pos- All authors of this article declare they have no
sible that we had high rates of cigarette smoking in conflicts of interest.
our sample because the study was advertised as an
Tob Regul Sci.™ 2021;7(2):87-102 DOI: doi.org/10.18001/TRS.7.2.1 99Pack Modifications Influence Perceptions of Menthol E-cigarettes
Acknowledgements uary 2015 through October 2019. Am J Public Health.
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Tob Regul Sci.™ 2021;7(2):87-102 DOI: doi.org/10.18001/TRS.7.2.1 101You can also read
