Pack Modifications Influence Perceptions of Menthol E-cigarettes

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Pack Modifications Influence Perceptions of Menthol E-cigarettes
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
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

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Pack Modifications Influence Perceptions of Menthol E-cigarettes
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
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

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Cohn 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                     91
Pack 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.

92
Cohn 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                                 93
Pack 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

94
Table 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 al
Pack 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

96
Cohn 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                     97
Pack 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                    99
Pack Modifications Influence Perceptions of Menthol E-cigarettes

Acknowledgements                                                      uary 2015 through October 2019. Am J Public Health.
                                                                      2020; 110(6):785-787.
  Research reported in this publication was sup-                  15. Manning KC, Kelly KJ, Comello ML. Flavoured ciga-
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Health. Portions of this manuscript were presented                17. Anderson SJ. Marketing of menthol cigarettes and con-
at the annual Tobacco Regulatory Science Meet-                        sumer perceptions: a review of tobacco industry docu-
ing in October 2019. We thank Lexie Perreras who                      ments. Tob Control. 2011;20(Suppl 2):ii20-ii28.
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Tob Regul Sci.™ 2021;7(2):87-102                                  DOI: doi.org/10.18001/TRS.7.2.1                           101
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