“Keep Calm, it's just Vapour”: A Mixed Methods Investigation of Online E-Cigarette Discourse and User Perspectives in Western Australia

The aim of this research was to understand how electronic cigarettes (e-cigarettes) are promoted, accessed, and used within a tightly regulated environment, by exploring the Australian online e-cigarette discourse, and the perspectives of e-cigarette users residing within the Greater Capital City Statistical Area of Perth, Western Australia. To achieve this aim three substudies were undertaken: a) scoping review, b) Twitter inquiry and c) qualitative inquiry

The messages presented in online electronic cigarette promotions and discussions: a scoping review protocol

Introduction: Electronic cigarettes have become increasingly popular over the last 10 years. These devices represent a new paradigm for tobacco control offering smokers an opportunity to inhale nicotine without inhaling tobacco smoke. To date there are no definite conclusions regarding the safety and long-term health effects of electronic cigarettes; however, there is evidence that they are being marketed online as a healthier alternative to traditional cigarettes. This scoping review aims to identify and describe the breadth of messages (eg, health, smoking-cessation and price related claims) presented in online electronic cigarette promotions and discussions. Methods and analysis: A scoping review will be undertaken adhering to the methodology outlined in The Joanna Briggs Institute Manual for Scoping Reviews. Six key electronic databases will be searched to identify eligible studies. Studies must be published in English between 2007 and 2017, examine and/or analyse content captured from online electronic cigarette promotions or discussions and report results for electronic cigarettes separately to other forms of tobacco delivery. Studies will be screened initially by title and abstract, followed by full-text review. Results of the search strategy will be reported in a PRISMA flow diagram and presented in tabular form with accompanying narrative summary. Ethics and dissemination: The methodology consists of reviewing and collecting data from publicly available studies, and therefore does not require ethics approval. Results will be published in a peer reviewed journal and be presented at national/international conferences. Additionally, findings will be disseminated via social media and online platforms. Advocacy will be key to informing policy makers of regulatory and health issues that need to be addressed. Registration details: The review was registered prospectively with The Joanna Briggs Institute Systematic Reviews database

The Messages Presented in Electronic Cigarette-Related Social Media Promotions and Discussion: Scoping Review.

BACKGROUND: There has been a rapid rise in the popularity of electronic cigarettes (e-cigarettes) over the last decade, with growth predicted to continue. The uptake of these devices has escalated despite inconclusive evidence of their efficacy as a smoking cessation device and unknown long-term health consequences. As smoking rates continue to drop or plateau in many well-developed countries, transnational tobacco companies have transitioned into the vaping industry and are now using social media to promote their products. Evidence indicates e-cigarettes are being marketed on social media as a harm reduction alternative, with retailers and manufacturers utilizing marketing techniques historically used by the tobacco industry. OBJECTIVE: This study aimed to identify and describe the messages presented in e-cigarette-related social media (Twitter, YouTube, Instagram, and Pinterest) promotions and discussions and identify future directions for research, surveillance, and regulation. METHODS: Data sources included MEDLINE, Scopus, ProQuest, Informit, the Journal of Medical Internet Research, and Google Scholar. Included studies were published in English between 2007 and 2017, analyzed content captured from e-cigarette-related social media promotions or discussions, and reported results for e-cigarettes separately from other forms of tobacco and nicotine delivery. Database search ceased in October 2017. Initial searches identified 536 studies. Two reviewers screened studies by title and abstract. One reviewer examined 71 full-text articles to determine eligibility and identified 25 studies for inclusion. This process was undertaken with the assistance of the Web-based screening and data extraction tool-Covidence. The review was registered with the Joanna Briggs Institute (JBI) Systematic Reviews database and followed the methodology for JBI Scoping Reviews. RESULTS: Several key messages are being used to promote e-cigarettes including as a safer alternative to cigarettes, efficacy as a smoking cessation aid, and for use where smoking is prohibited. Other major marketing efforts aimed at capturing a larger market involve promotion of innovative flavoring and highlighting the public performance of vaping. Discussion and promotion of these devices appear to be predominantly occurring among the general public and those with vested interests such as retailers and manufacturers. There is a noticeable silence from the public health and government sector in these discussions on social media. CONCLUSIONS: The social media landscape is dominated by pro-vaping messages disseminated by the vaping industry and vaping proponents. The uncertainty surrounding e-cigarette regulation expressed within the public health field appears not to be reflected in ongoing social media dialogues and highlights the need for public health professionals to interact with the public to actively influence social media conversations and create a more balanced discussion. With the vaping industry changing so rapidly, real-time monitoring and surveillance of how these devices are discussed, promoted, and used on social media is necessary in conjunction with evidence published in academic journals

“Is it banned? Is it illegal?”: Navigating Western Australia's regulatory environment for e-cigarettes

Background: In Australia, there is no Federal legislation that directly applies to e-cigarettes, instead, several existing laws relating to poisons, therapeutic goods and tobacco control apply. Across all Australian States and Territories, it is illegal to sell nicotine-containing e-cigarettes, however, users can legally import nicotine-containing vaporisers through the Personal Importation Scheme. Western Australia differs from other Australian States and Territories in that products which resemble tobacco products are banned, effectively prohibiting the use of e-cigarettes. This study aimed to understand how e-cigarette users navigate Western Australia's regulatory environment to access vaping products and the health and safety issues encountered. Methods: Working from a constructionist epistemology and a symbolic interaction framework, in-depth interviews were conducted with a purposive sample of 37 current (89%) and former (11%) adult vapers (70% male, mean age of 32.5). Data was analysed via thematic analysis. Results: Vape retailers were said to be circumventing Western Australia's e-cigarette restrictions by selling the components of ‘open system’ devices that do not resemble a tobacco product when sold individually. Participants were unsure of the legality of importing, accessing and using nicotine and e-cigarettes, however, the majority continued to use nicotine-containing vaporisers and implemented strategies in an attempt to avoid detection and safeguard their health. The internet facilitated access to desired products, information on health and safety, and discussions of personal experiences. Conclusions: The Australian Therapeutic Goods Administration has recently (21 December 2020) confirmed that from 1 October 2021 smokers who have tried quitting with other approved cessation pharmacotherapies will be required to obtain a prescription for nicotine-containing vaporiser products from a registered medical practitioner. The results of this study suggest further consideration of regulatory measures are however required to support the different characteristics of vapers and to mitigate the health and safety concerns experienced by e-cigarette users

Perceptions of social media harms and potential management strategies: Vaping case study

Background The social media landscape is now ubiquitous in people’s everyday lives. It is a space where culture, politics, economics and sociological and public health discourses occur. There is mounting evidence that e-cigarette products are being promoted and advertised on social media, a media platform particularly popular with young people. Our research aimed to understand industry professionals’ perceptions of social media harms and potential management strategies using vaping as a case study. Methods A critical realist perspective guided reflexive thematic analysis of the qualitative in depth, semi structured interviews. Data collection occurred in January and February 2023 with 13 participants working in the areas of public health, digital media, law, governance, tobacco control and advocacy. Results Two superordinate themes emerged from the data: (1) Fathoming a complex system (social media) that contained the subordinate themes of Traversing Boundaries (crossing borders, crossing sectors) and Ungovernable (global and local landscapes, vested interests, self-regulation and opacity). (2) Addressing complexity (social media)– that contained the subordinate themes of Strengthening Institutions (global to local, policy and legislation, individuals and organisations); Defanging Industry (responsibility and transparency, moderation and algorithms, complaints); and Engaging Citizens (raising awareness, framing messaging). Conclusions There was consensus among participants that e-cigarette related social media content can be harmful and government action is urgently needed. There was an identified need for the development of government led national-level regulatory frameworks, with government led appropriate legislation; identification of an organisation or organisations with suitable levels of regulatory power and resources to monitor, enforce and penalise noncompliant social media companies; accompanied by increased community awareness raising of harmful social media content and improved digital literacy

A research and evaluation capacity building model in Western Australia

Evaluation of public health programs, services and policies is increasingly required to demonstrate effectiveness. Funding constraints necessitate that existing programs, services and policies be evaluated and their findings disseminated. Evidence-informed practice and policy is also desirable to maximise investments in public health. Partnerships between public health researchers, service providers and policymakers can help address evaluation knowledge and skills gaps. The Western Australian Sexual Health and Blood-borne Virus Applied Research and Evaluation Network (SiREN) aims to build research and evaluation capacity in the sexual health and blood-borne virus sector in Western Australia (WA). Partners’ perspectives of the SiREN model after 2 years were explored. Qualitative written responses from service providers, policymakers and researchers about the SiREN model were analysed thematically. Service providers reported that participation in SiREN prompted them to consider evaluation earlier in the planning process and increased their appreciation of the value of evaluation. Policymakers noted benefits of the model in generating local evidence and highlighting local issues of importance for consideration at a national level. Researchers identified challenges communicating the services available through SiREN and the time investment needed to develop effective collaborative partnerships. Stronger engagement between public health researchers, service providers and policymakers through collaborative partnerships has the potential to improve evidence generation and evidence translation. These outcomes require long-term funding and commitment from all partners to develop and maintain partnerships. Ongoing monitoring and evaluation can ensure the partnership remains responsive to the needs of key stakeholders. The findings are applicable to many sectors

A Review of Drowning Prevention Interventions for Children and Young People in High, Low and Middle Income Countries.

Globally, drowning is one of the ten leading causes of child mortality. Children aged <5 years are particularly at risk, and children and young people continue to be overrepresented in drowning statistics. Accordingly, evidence informed interventions to prevent children drowning are of global importance. This review aimed to identify, assess and analyse public health interventions to reduce child drowning and investigate the use of behavioural theories and evaluation frameworks to guide child drowning prevention. Thirteen databases were searched for relevant peer reviewed articles. The systematic review was guided by the PRISMA criteria and registered with PROSPERO. Fifteen articles were included in the final review. Studies were delivered in high, middle and low income countries. Intervention designs varied, one-third of studies targeted children under five. Almost half of the studies relied on education and information to reduce drowning deaths, only three studies used a multi-strategy approach. Minimal use of behavioural theories and/or frameworks was found and just one-third of the studies described formative evaluation. This review reveals an over reliance on education and information as a strategy to prevent drowning, despite evidence for comprehensive multi-strategy approaches. Accordingly, interventions must be supported that use a range of strategies, are shaped by theory and planning and evaluation frameworks, and are robust in intervention design, delivery and evaluation methodology. This approach will provide sound evidence that can be disseminated to inform future practice and policy for drowning prevention

The emergence of e-cigarette retail shops in a regulated tobacco control environment

Issue addressed: E-cigarettes are of growing concern. We aimed to determine the location and characteristics of retail shops selling e-cigarette products in Perth, Western Australia. Methods: Two phase study: (i) identifying all e-cigarette retailers in the Greater Capital City Statistical Area of Perth; (ii) audit at the point-of-sale to assess products, promotions and shop characteristics (n = 41). Results: Ninety-eight retailers selling e-cigarette products were identified: 43 tobacconists (44%), 21 vape shops (21% – up from one shop in 2017), 14 supermarkets (14%), 12 service stations (12%) and 8 smoke shops (8%). The most common e-cigarette product was non-nicotine e-liquid, available at 38 (93%) stores audited. Most stores sold parts of e-cigarette devices (n = 25, 61%). Front counter displays were the most frequent form of promotion (n = 40, 98%). Vape shops differed from other retailers, having bar-style layouts (n = 15, 71%), lounge areas (n = 7, 33%) and free e-liquid samples (n = 17, 89%). Conclusion: The availability of e-cigarette products from retail shops and particularly vape shops is increasing. E-cigarette retailers are using traditional promotional techniques including point-of-sale displays to market their products, while vape shops are extending their appeal through bar style, lounge layouts and free trials. Implications for public health: Understanding the e-cigarette retail store environment is essential for identifying emergent trends, potential regulations and future research. So what?: The e-cigarette retail market in the Perth is growing, shops using traditional and new promotional techniques to market e-cigarette products. Our findings identify a need for public health surveillance, regulations and legislation

E-Cigarettes: Implications for Health Promotion in the Asian Pacific Region

© 2018, APJPH. Since their introduction to the United States in 2007, electronic cigarettes (e-cigarettes) use has grown exponentially. This rapid growth in e-cigarette use has been heralded by some as a potential important public health measure that could ultimately replace tobacco cigarettes, while others recommend a cautionary approach until there is clear evidence they will not become “new tobacco” bringing a possible myriad of other problems. E-cigarettes may have real benefits, however they do expose users and those nearby to organic compounds, solvents and particulate matter, with there being limited data relating to their health impact. It is unclear as to whether this relatively new device has the potential to exacerbate nicotine addictions, or play a part in reducing harm and smoking cessation. The fundamental requirement of public health practice is to do no harm and from the inconclusive evidence we have to date on e-cigarettes, it appears a cautious approach is warranted. This commentary reviews evidence that supports a cautious approach to e-cigarette availability in Australia and the Asian Pacific region

Envisaging a ‘smoke-free’ world: An exploratory study of Philip Morris International’s strategic positioning in Australia

The World Health Organization (WHO) has declared tobacco smoking a global health epidemic, citing 8 million deaths and an economic cost of around 1.4 trillion USD per year. Under a UN mandate a global voluntary target was established in 2013 to reduce the prevalence of tobacco use, with varying success rates across the globe to date. While there has been a gradual reduction in combustible cigarette smoking rates across the developed world (Drope et al., 2018), there has been a sharp increase in the popularity and usage of electronic cigarettes (e-cigarettes) since their introduction in 2003 (Drope et al., 2018; McCausland, Maycock, Leaver, & Jancey, 2019). The tobacco and vaping industries claim that e-cigarettes products are less harmful than traditional cigarettes as they are non-combustible, and produce an aerosol with fewer toxic elements like tar and carbon monoxide (Hajek, Etter, Benowitz, Eissenberg, & McRobbie, 2014; Simonavicius, McNeill, Shahab, & Brose, 2018). Indeed, as combustible cigarettes become less socially acceptable and demand decreases, the tobacco industry has increasingly positioned e-cigarettes as part of the solution to reach the WHO’s smoking reduction targets. E-cigarette uptake in Australia remains comparatively low to that in other developed nations (Greenhalgh & Scollo, 2018). This is likely the result of current laws preventing the sale of e-cigarettes containing nicotine in all Australian states and territories due to nicotine’s classification as a schedule 7 ‘dangerous poison’ (Greenhalgh, Grace, & Scollo, 2019). However, given the success of targeted public health policies, such as the Australian Federal laws banning smoking in enclosed places, increased taxing of tobacco products and the introduction of the world’s first plain packaging laws in 2012 (Scollo & Greenhalgh, 2018), the tobacco industry’s lobbying efforts have shifted to establish e-cigarettes as a socially acceptable alternative. Philip Morris International (PMI) controls the main share of the global tobacco market and is the second biggest tobacco company in Australia (Freeman, Winstanley, & Bayly, 2019). This study used framing theory to critically analyse corporate communication materials from PMI to identify the prevailing themes used to challenge Australia’s existing e-cigarette regulations and garner public support for broader access to nicotine containing e-cigarette products. The inclusion criteria for data collection were materials published between January 2018 and July 2019 relating to PMI’s e-cigarettes, heat-not-burn (HNB) products or ‘smokefree’ transformation. 1,534 items were identified for thematic analysis, covering posts across PMI’s social media accounts, media releases, news articles, reports, whitepapers, communication to public health professionals, as well as submissions to two government enquiries. Seven themes and 19 sub-themes emerged from this data. Tobacco Harm Reduction emerged as the dominant theme from the thematic analysis, with references to harm reduction woven through most materials. Other key frames include; PMI as a good corporate citizen, advocating on behalf of smokers, lobbying governments, science and innovation, improved public health outcomes and justifying the presence of nicotine in their Reduced-Risk Products (RRPs). The authors argue that the frame of science and innovation is crucial in understanding how PMI attempts to build trust among consumers; investors and shareholders; lobby government; and divide the public health sector. PMI use extensive research and development expenditure to add credibility to harm reduction claims of their RRPs and to consequently legitimise their claimed position of authority. Indeed, PMI appears to position themselves as the ‘white knight’ of society, campaigning to improve health outcomes, where the public health sector has apparently failed. Given PMI’s status as a leading transnational tobacco corporation, study findings arguably inform the understanding of communication and strategic positioning strategies used by the global tobacco industry and hence may inform future public health campaigns