Youth Exposure to Warnings on Cigar, E-Cigarette, and Waterpipe Tobacco Packages


      Studies of tobacco product warnings have focused primarily on the reach and effectiveness of cigarette warnings for adult smokers, whereas few observational studies have examined noncigarette tobacco product warnings among youth.


      High school students from the 2019 National Youth Tobacco Survey (n=10,094) reported the frequency of exposure to warnings on cigar, e-cigarette, and waterpipe tobacco packages and the perceived harm of occasionally using e-cigarettes and waterpipe tobacco. In 2020, results were analyzed for the entire sample and among subgroups, including never users, ever users, youth susceptible to using tobacco, and current users.


      Reported high exposure to warnings was highest for cigars (22.3%), followed by that for e-cigarettes (20.8%) and that for waterpipe tobacco (7.0%). Youth who were susceptible to using cigars (AOR=1.53, 95% CI=1.29, 1.82), who ever used cigars (AOR=4.32, 95% CI=3.57, 5.22), or who currently used cigars (AOR=8.90, 95% CI=6.95, 11.39) were more likely to report high exposure to cigar warnings than youth who never used cigars. Similar findings were observed for e-cigarette and waterpipe tobacco warnings. For youth who ever used e-cigarettes, high exposure to warnings was associated with higher odds of perceiving e-cigarettes as harmful for occasional product use (AOR=1.50, 95% CI=1.05, 2.15), and high exposure to waterpipe tobacco warnings was associated with higher odds of perceiving waterpipe tobacco as harmful (AOR=1.21, 95% CI=1.00, 1.45).


      Warnings on noncigarette tobacco products reach some youth at risk for using these products, but these warnings may need to be strengthened to further reduce their use.
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        • WHO
        WHO report on the global tobacco epidemic 2019: offer help to quit tobacco use.
        WHO, Geneva, SwitzerlandPublished July 25, 2019
        • HHS
        Smoking cessation: a report of the Surgeon General.
        HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GAPublished 2020 ( Accessed November 21, 2020)
        • Gentzke AS
        • Creamer M
        • Cullen KA
        • et al.
        Vital signs: tobacco product use among middle and high school students—United States, 2011-2018.
        MMWR Morb Mortal Wkly Rep. 2019; 68: 157-164
        • HHS
        The health consequences of smoking—50 years of progress: a report of the Surgeon General.
        HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GAPublished January 2014
        • Noar SM
        • Francis DB
        • Bridges C
        • Sontag JM
        • Ribisl KM
        • Brewer NT.
        The impact of strengthening cigarette pack warnings: systematic review of longitudinal observational studies.
        Soc Sci Med. 2016; 164: 118-129
        • Noar SM
        • Hall MG
        • Francis DB
        • Ribisl KM
        • Pepper JK
        • Brewer NT.
        Pictorial cigarette pack warnings: a meta-analysis of experimental studies.
        Tob Control. 2016; 25: 341-354
        • Noar SM
        • Francis DB
        • Bridges C
        • Sontag JM
        • Brewer NT
        • Ribisl KM.
        Effects of strengthening cigarette pack warnings on attention and message processing: a systematic review.
        Journal Mass Commun Q. 2017; 94: 416-442
        • Monárrez-Espino J
        • Liu B
        • Greiner F
        • Bremberg S
        • Galanti R.
        Systematic review of the effect of pictorial warnings on cigarette packages in smoking behavior [published correction appears in Am J Public Health. 2015;105(2):e5].
        Am J Public Health. 2014; 104: e11-e30
        • Francis DB
        • Mason N
        • Ross JC
        • Noar SM.
        Impact of tobacco-pack pictorial warnings on youth and young adults: a systematic review of experimental studies.
        Tob Induc Dis. 2019; 17: 41
        • Johnson SE
        • Wu CC
        • Coleman BN
        • Choiniere CJ.
        Self-reported exposure to tobacco warning labels among U.S. middle and high school students.
        Am J Prev Med. 2014; 47: S69-S75
        • Thrasher JF
        • Brewer NT
        • Niederdeppe J
        • et al.
        Advancing tobacco product warning labels research methods and theory: a summary of a grantee meeting held by the U.S. National Cancer Institute.
        Nicotine Tob Res. 2019; 21: 855-862
        • Cornacchione Ross J
        • Noar SM
        • Sutfin EL
        Systematic review of health communication for non-cigarette tobacco products.
        Health Commun. 2019; 34: 361-369
      1. “Covered” tobacco products and roll-your-own/cigarette tobacco labeling and warning statement requirements.
        U.S. Food and Drug Administration, Updated June 10, 2020
      2. Cigar labeling and warning statement requirements. U.S. Food and Drug Administration.
        Updated June 10, 2020
        • Wackowski OA
        • Kurti M
        • Schroth KRJ
        • Delnevo CD.
        Examination of voluntary compliance with new FDA cigar warning label requirements.
        Tob Regul Sci. 2020; 6: 379-383
        • Sontag JM
        • Wackowski OA
        • Hammond D.
        Baseline assessment of noticing e-cigarette health warnings among youth and young adults in the United States, Canada and England, and associations with harm perceptions, nicotine awareness and warning recall.
        Prev Med Rep. 2019; 16100966
        • King JL
        • Reboussin BA
        • Cornacchione Ross J
        • Sutfin EL
        Waterpipe tobacco package warning exposure's impact on risk perceptions and use among young adults in the USA: a longitudinal analysis of the population assessment of tobacco and health study.
        Tob Control. 2019; 28: e16-e23
        • Wang TW
        • Gentzke AS
        • Creamer MR
        • et al.
        Tobacco product use and associated factors among middle and high school students - United States, 2019.
        MMWR Surveill Summ. 2019; 68: 1-22
        • Hammond D.
        Health warning messages on tobacco products: a review.
        Tob Control. 2011; 20: 327-337
        • Pepper JK
        • Coats EM
        • Nonnemaker JM
        • Loomis BR.
        How do adolescents get their e-cigarettes and other electronic vaping devices?.
        Am J Health Promot. 2019; 33: 420-429
        • Baker HM
        • Kowitt SD
        • Meernik C
        • et al.
        Youth source of acquisition for e-cigarettes.
        Prev Med Rep. 2019; 16101011
        • Trapl ES
        • O'Rourke-Suchoff D
        • Yoder LD
        • Cofie LE
        • Frank JL
        • Fryer CS.
        Youth acquisition and situational use of cigars, cigarillos, and little cigars: a cross-sectional study.
        Am J Prev Med. 2017; 52: e9-e16
        • Sutfin EL
        • Soule EK
        • McKelvey K
        • Jenson D.
        Implications and challenges for implementation of the FDA's final deeming rule for waterpipe tobacco.
        Tob Control. 2018; 27: 347-351
        • Kasza KA
        • Ambrose BK
        • Conway KP
        • et al.
        Tobacco-product use by adults and youths in the United States in 2013 and 2014 [published correction appears in N Engl J Med. 2018;378(5):492].
        N Engl J Med. 2017; 376: 342-353
        • Amrock SM
        • Lee L
        • Weitzman M.
        Perceptions of e-cigarettes and noncigarette tobacco products among U.S. youth.
        Pediatrics. 2016; 138e20154306
        • Pokhrel P
        • Herzog TA
        • Fagan P
        • Unger JB
        • Stacy AW.
        E-cigarette advertising exposure, explicit and implicit harm perceptions, and e-cigarette use susceptibility among nonsmoking young adults.
        Nicotine Tob Res. 2019; 21: 127-131
        • Klein EG
        • Berman M
        • Hemmerich N
        • Carlson C
        • Htut S
        • Slater M.
        Online e-cigarette marketing claims: a systematic content and legal analysis.
        Tob Regul Sci. 2016; 2: 252-262
        • Wagoner KG
        • Berman M
        • Rose SW
        • et al.
        Health claims made in vape shops: an observational study and content analysis.
        Tob Control. 2019; 28: e119-e125
        • Morean ME
        • Bold KW
        • Kong G
        • et al.
        Adolescents’ awareness of the nicotine strength and e-cigarette status of JUUL e-cigarettes.
        Drug Alcohol Depend. 2019; 204107512
        • Willett JG
        • Bennett M
        • Hair EC
        • et al.
        Recognition, use and perceptions of JUUL among youth and young adults.
        Tob Control. 2019; 28: 115-116
        • Pepper JK
        • Farrelly MC
        • Watson KA.
        Adolescents’ understanding and use of nicotine in e-cigarettes.
        Addict Behav. 2018; 82: 109-113
        • Alexander JP
        • Williams P
        • Lee YO.
        Youth who use e-cigarettes regularly: a qualitative study of behavior, attitudes, and familial norms [published correction appears in Prev Med Rep. 2020;20:101282].
        Prev Med Rep. 2019; 13: 93-97
        • Wackowski OA
        • Sontag JM
        • Hammond D
        • et al.
        The impact of e-cigarette warnings, warning themes and inclusion of relative harm statements on young adults’ e-cigarette perceptions and use intentions.
        Int J Environ Res Public Health. 2019; 16: 184
        • Mays D
        • Smith C
        • Johnson AC
        • Tercyak KP
        • Niaura RS.
        An experimental study of the effects of electronic cigarette warnings on young adult nonsmokers’ perceptions and behavioral intentions.
        Tob Induc Dis. 2016; 14: 17
        • Kok G
        • Peters GY
        • Kessels LTE
        • Ten Hoor GA
        • Ruiter RAC
        Ignoring theory and misinterpreting evidence: the false belief in fear appeals.
        Health Psychol Rev. 2018; 12: 111-125
        • Brewer NT
        • Parada H
        • Hall MG
        • Boynton MH
        • Noar SM
        • Ribisl KM.
        Understanding why pictorial cigarette pack warnings increase quit attempts.
        Ann Behav Med. 2019; 53: 232-243
        • Noar SM
        • Rohde JA
        • Barker JO
        • Hall MG
        • Brewer NT.
        Pictorial cigarette pack warnings increase some risk appraisals but not risk beliefs: a meta-analysis.
        Hum Commun Res. 2020; 46: 250-272
        • Corey CG
        • King BA
        • Coleman BN
        • et al.
        Little filtered cigar, cigarillo, and premium cigar smoking among adults—United States, 2012-2013.
        MMWR Morb Mortal Wkly Rep. 2014; 63 ( Accessed November 21, 2020): 650-654
        • Delnevo CD
        • Giovenco DP
        • Miller Lo EJ
        Changes in the mass-merchandise cigar market since the Tobacco Control Act.
        Tob Regul Sci. 2017; 3: S8-S16
        • Odani S
        • Armour BS
        • Agaku IT.
        Racial/ethnic disparities in tobacco product use among middle and high school students - United States, 2014-2017.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 952-957