Health Warnings on Instagram Advertisements for Synthetic Nicotine E-Cigarettes and Engagement

Synthetic nicotine is increasingly used in e-cigarette liquids along with flavors to appeal to youths. Regulatory loopholes have allowed tobacco manufacturers to use social media to target youths.

To analyze the extent to which synthetic nicotine e-cigarette brands have implemented US Food and Drug Administration (FDA) health warning requirements and to evaluate the association between health warnings and user engagement on Instagram.

In this cross-sectional study, posts from 25 brands were analyzed across a 14-month period (August 2021 to October 2022). A content analysis was paired with Warning Label Multi-Layer Image Identification, a computer vision algorithm designed to detect the presence of health warnings and whether the detected health warning complied with FDA guidelines by (1) appearing on the upper portion of the advertisement and (2) occupying at least 20% of the advertisement's area. Data analysis was performed from March to June 2024.

Synthetic nicotine e-cigarette advertisement on Instagram.

The outcome variables were user engagement (number of likes and comments). Negative binomial regression analyses were used to evaluate the association between the presence and characteristics of health warnings and user engagement.

Of a total of 2071 posts, only 263 (13%) complied with both FDA health warning requirements. Among 924 posts with health warnings, 732 (79%) displayed warnings in the upper image portion, and 270 (29%) had a warning covering at least 20% of the pixel area. Posts with warnings received fewer comments than posts without warnings (mean [SD], 1.8 [2.5] vs 5.4 [11.7] comments; adjusted incident rate ratio [aIRR], 0.70; 95% CI, 0.57-0.86; P < .001). For posts containing warnings, a larger percentage of the warning label's pixel area was associated with fewer comments (aIRR, 0.96; 95% CI, 0.93-0.99; P = .003). Flavored posts with health warnings placed in the upper image portion received more likes than posts with warnings in the lower portion (mean [SD], 34.6 [35.2] vs 19.9 [19.2] likes; aIRR, 1.48; 95% CI, 1.07-2.06; P = .02).

In this cross-sectional study of synthetic nicotine brand Instagram accounts, 87% of sampled posts did not adhere to FDA health warning requirements in tobacco promotions. Enforcement of FDA compliant health warnings on social media may reduce youth engagement with tobacco marketing.