Purchase Intent and Appeal of ENDS Products among Current, Former and Never Ever Users of Tobacco Products in the U.S.

Cigarette smoking is the leading cause of preventable premature mortality in the United States, with combustion identified as the primary source of carcinogens associated with tobacco use (1). Therefore, non-combustible tobacco and nicotine products like e-cigarettes are associated with less harm than cigarettes (2, 3). E-cigarettes have been developed to encourage adult smokers to use less harmful products, reduce overall cigarette consumption, and to address important Healthy People public health goals (4, 5). At the same time, public health is also concerned with preventing smoking initiation and sustaining long-term smoking cessation to reduce smoking-related morbidity and mortality (6, 7). To meet these objectives, it is important for non-combustible tobacco and nicotine products to appeal to current smokers and not to nonusers of tobacco products, including both former and never users of tobacco.

The last decade bore witness to dramatically increased awareness, trial, and use of e-cigarettes among both the intended users (i.e., adult smokers) and unintended populations (i.e., nonsmokers, including youth and young adults) (8) before the U.S. Food and Drug Administration (FDA) began reviewing premarket applications for e-cigarettes in September 2020. FDA guidance (9, 10) states that to receive market authorization, a new tobacco product must be appropriate for the protection of public health by considering the extent to which it decreases use of combustible products among current smokers relative to the extent to which it leads to any increase in use among nonusers. As part of its guidance, FDA recommends that ENDS manufacturers provide population-level estimates of behavioral intentions and product appeal of their products among both tobacco users and nonusers. Although there are several published reports in the tobacco literature about behavioral intentions (11–17) and product appeal (18–24), those reports do not provide population-level estimates that are critical to evaluating the impact of products on public health. The present work addresses this data gap.

This analysis provides population estimates of both purchase intent and product appeal among adult tobacco users (current established cigarette smokers, current established non-cigarette tobacco users, current tobacco experimenters) and nonusers (former tobacco users, and never ever tobacco users) from a series of conducted studies¹ with three goals in mind. First, to provide population-level estimates of purchase intent and product appeal across tobacco user groups. Second, to describe how patterns of mean ratings of purchase intent and product appeal across tobacco user groups change when different products, or features within a particular product, are presented. Third, to examine the relationship between behavioral intentions and product appeal within tobacco user groups via correlational analyses.

Studies were conducted in accordance with International Organization for Standardization (ISO 20252:2019) guidelines. The Western Institutional Review Board reviewed each of the six study protocols before the start of the study. All studies were approved or received an exempt determination, and statistical analysis plans were developed prior to data collection.

Panel members who received an invitation and consented to participate answered screening questions to determine eligibility and to assess demographic characteristics and tobacco use history. Participants were presented with high-resolution color digital images prior to collection of purchase intent and appeal ratings.

These product images included product packaging, label, content, as well as available flavors and power units. The group of high resolution color images was presented on one to two pages and included all text information in a legible format (front, back, side panels, and top/bottom, if information was presented). Zooming in was enabled if participants wanted to see a magnified image. Brand names were visible on the packs, and for each product, the specific flavor varieties and power unit options (if any) were presented. After viewing the images of the test, participants were asked to rate: (a) their purchase intent on a 10-point scale ranging from 1 (definitely would not purchase it to use) to 10 (definitely would purchase it to use), and (b) product appeal on a 7-point scale ranging from 1 (not at all appealing) to 7 (extremely appealing).

Descriptive statistics (i.e., weighted means, with unweighted sample sizes, and weighted 95% confidence intervals, CIs) are presented for product appeal and purchase intent for the five tobacco user groups in each of the samples, as well as aggregated across the samples. In addition, weighted correlational analyses (Pearson’s R) between purchase intent ratings and product appeal ratings are presented for each tobacco user group within each sample. Data processing and analyses were conducted using SAS version 9.4 (30).

This analysis provides population-level estimates of purchase intent and appeal ratings for e-cigarettes across five tobacco user groups from 10 separate samples in which each set of respondents viewed different Vuse e-cigarettes that varied with respect to sub-brand, device style, nicotine strength, and different flavors and number of flavors. For both dependent variables – purchase intent and product appeal – mean ratings were consistently highest among current tobacco experimenters and lowest among never ever tobacco users. In addition, ratings are always higher among the three groups of current tobacco users (current established cigarette smokers, current established noncigarette tobacco users, and current tobacco experimenters) than among the two groups of nonusers (former tobacco users and never ever tobacco users). The consistency in the pattern of results across the tobacco user groups suggests that the types of product variations across the e-cigarettes presented are unlikely to have differential effects on public health (i.e., purchase intent and appeal among tobacco users and nonusers).

In contrast to the consistency in the pattern of results across tobacco user groups, there appears to be variability in purchase intent ratings within tobacco user groups across the samples, particularly among current tobacco experimenters (see Figure 2). That variability may reflect differential interest in the products presented to each sample or the impact of broader environmental variables associated with the timing of the various studies. This report cannot distinguish between those possibilities because the product presented to each sample and the timing of studies are confounded. However, the timing of those lower ratings corresponds to intense negative media coverage in 2019 associated with E-Cigarette, or Vaping, Product Use Associated Lung Injury (EVALI; 31, 32). Observing lower ratings after EVALI made headlines is consistent with findings from a study that compared perceptions of e-cigarettes from samples before and after EVALI made headlines (19) and a study that reports on less interests in using e-cigarettes among smokers who had heard about EVALI (33). Ratings across the studies appear to have rebounded after it was demonstrated that EVALI was primarily linked to vitamin E acetate added to certain THC containing vapor products rather than to nicotine ENDS products (34). That time-based decrease then rebound suggests that the effect is likely attributable to the broader environment rather than product differences. The observation that it appears to be largest among current tobacco experimenters suggests that they may be a more sensitive barometer to change than other tobacco user groups who are more set in their behaviors of either using, or not using, tobacco products. Despite strong correlations between the purchase intent and appeal metrics, there may be value in retaining both measures in future research.

The primary strength of this article is that the studies in it were conducted with a high degree of methodological rigor. All of the studies included large samples, employed quotas to allow for samples sizes for meaningful tobacco user group analyses, and used multi-step statistical weighting processes to yield weighted estimates that closely match the U.S. population, resulting in generalizable population-based estimates.

Limitations include that the samples were drawn from internet panels and would not include respondents who do not have access to the internet or those who choose not to join the panel. Panel surveys have, however, become widely used in population research. Another potential limitation, which is inherent in virtually all tobacco-related surveys, is that respondents are categorized based on selfreported tobacco use behavior. It is possible that respondents misrepresent their actual tobacco use behavior; however, the confidential nature of the data collection methodology ensures there is no incentive for respondents to provide inaccurate data regarding use behavior.

Mean purchase intent ratings and ratings of appeal are higher for current tobacco users (current established cigarette smokers, current established non-cigarette tobacco users, and current tobacco experimenters) than for former and never ever tobacco users. This pattern, which was observed across three different sub-brands/device types, from one to eight flavors, single or multiple nicotine levels (from 1.5% to 5.0%), and power unit colors, suggests that these vapor products do not differ with respect to their potential impact on public health insofar as these product design characteristics may influence product appeal and purchase intent.