FTC should collect and release detailed information on e-cigarette marketing and promotions

We just submitted the following public comment to the FTC regarding its proposal to monitor e-cigarette marketing.  This is not only valualbe in its own right, but would also provide useful information to the FDA should the Obama Administration actually let the FDA do anything about e-cigarettes.  The comment is also available as a PDF here.  The FTC tracking number is 00032.
Detailed information and reports on electronic cigarette marketing and sales is essential for understanding the skyrocketing popularity and use of various electronic cigarette products among youth and young adults
FTC File No. P144504
Lauren K. Lempert, JD MPH
Benjamin W. Chaffee, DDS PhD
Lucy Popova, PhD
Bonnie Halpern-Felsher, PhD
Margarete C. Kulik, PhD
Stanton A. Glantz, PhD
UCSF Tobacco Center for Regulatory Science
Center for Tobacco Control Research and Education
University of California, San Francisco
FTC proposal is at  https://ftcpublic.commentworks.com/FTC/InitiativeDocFiles/750/Notice.pdf
This public comment is posted at: https://ftcpublic.commentworks.com/ftc/electroniccigarettespra/
December 27. 2015
Electronic cigarette marketing attracts youth and young adults and has contributed to skyrocketing use of these products, as well as poly-use of e-cigarettes along with other tobacco products.  E-cigarettes have also contributed to the renormalization of other tobacco products.  Thus, the proposed FTC data and reports would help public health researchers develop the information necessary to inform policies to counteract these effects.
Expenditures on electronic cigarette marketing have sharply increased in recent years, particularly through media no longer available to traditional tobacco products,[1] and primarily by the brands owned by the major tobacco companies.[2]  This advertising is effectively reaching youth, and is likely contributing to the skyrocketing popularity of electronic cigarettes among youth.[3]  Electronic cigarette marketing, especially marketing targeted at youth and marketing that mimics traditional cigarette marketing, almost certainly contributes to poly-use of electronic cigarettes and other tobacco products.[4]  The proposed FTC information gathering and reports can help the public health community understand how marketing and sales affect electronic cigarette use among youth and adults, and to counteract this effect.  FTC reports on electronic cigarette marketing and sales is essential and the information gathered would help the public health community to counteract the marketing of electronic cigarettes to youth that increases the use of these addictive products and re-normalizes smoking.
The FTC’s proposed collection and reporting of detailed information on sales, give-aways, marketing, and other promotion of electronic cigarettes can help the public health community better understand the variety of electronic cigarette products, where and how they are being sold, and how much is being spent to advertise and promote these products, and is therefore critical for evaluating how electronic cigarette marketing and promotion affects youth and young adult uptake and sustained use of electronic cigarettes.
It is likely that electronic cigarette marketing influences adolescents’ perceptions of the social norms, risks, and appeal of other tobacco products, such as cigarettes. Therefore, detailed, timely, and accurate data on all marketing and advertising efforts are essential for high-quality research and surveillance that can inform appropriate, evidence-based public policy in relation to electronic cigarette marketing and youth tobacco prevention and control.
The US Surgeon General has concluded that, “Advertising and promotional activities by tobacco companies have been shown to cause the onset and continuation of smoking among adolescents and young adults.”[5]  FTC’s reports on cigarette sales and marketing have been important to the substantial body of research that has led to this important conclusion.  Increases in electronic cigarette marketing are almost certainly contributing to expanded youth electronic cigarette use and must be monitored in detail.   FTC’s proposed information gathering and reports on electronic cigarette marketing and sales will provide invaluable information for scholarly research on electronic cigarette initiation and expanding use among youth and adolescents.
FTC can enhance the quality, utility, and clarity of the information to be collected by differentiating the data by type of device and brand and tracking marketing and sales data over time.
The collection of detailed information on electronic cigarette sales, including by type of device and by brand, will allow tobacco control researches and policymakers to track the increasing prevalence of electronic cigarette use, and specifically which devices (e.g., cig-a-likes vs mods) are being advertised and sold most, and these trends change over time and are related to actual use among adolescents and young adults.  It is important to track electronic cigarette sales data over time, and to relate this information to changes in adolescent, young adult and adult usage, social norms, and perceptions as a function of these sales and marketing changes.  In particular, such information will allow scientists and economists to examine specific changes in types of marketing, venues where marketing is occurring, and how marketing strategies change over time.  It will also allow verifying levels of self-reported electronic cigarette use as reported in surveys.  
FTC should collect data on product sales separately from data on product give-aways, and should also collect separate data on promotions such as coupons and discounts.
It is critical that the FTC collect information on product give-aways, in addition to and separate from sales data, as electronic cigarette give-aways have a strong potential to reach minors, even if youth access restrictions are in place.  From the mid-1970s to 1980s, cigarette companies rapidly increased expenditures devoted to the distribution of free cigarette samples, and, despite a voluntary code from the tobacco industry not to distribute to minors, 1 in 5 high school students surveyed in 1982 reported receiving cigarettes as product give-aways.[6]  Further, FTC should collect data on product sales separately from data on product give-aways because the two activities might be targeting different population groups.
In addition to tracking physical product give-aways, the FTC should monitor promotions, such as coupons (by mail and e-mail) or other Internet-based discounts or give-aways, for which age restrictions are problematic. In 2012, exposure to tobacco coupons was not uncommon among youth (approximately 13% of U.S. middle and high school students had been exposed to tobacco coupons), and coupon exposure was strongly associated with tobacco use.[7]
The collection of differentiated and detailed data on electronic cigarette marketing and sales is necessary to monitor youth impact and to evaluate the effectiveness of any safeguards against youth exposure.
The FTC should collect data to the level of detail that allows separate analysis of sales, marketing, give-aways, and other promotions by geographic region, time during which the activities occurred, and nature of the promotion (e.g. e-mail, social media, traditional mass media [separately for television, radio, and print], and physical give-aways) and whether and what measures are in place to prevent youth exposure. This information is necessary to monitor youth impact and to evaluate the effectiveness of any safeguards against youth exposure. The data are also important to evaluate whether regional differences in specific sales, marketing, give-aways and other promotional translates to changes in youth and young adult perceptions of risks, social norms, and ultimately use.  Such information will be important in informing regulation and targeted educational efforts.    
Rates of use and market share
Presently, we have very little data on rates of use, and the currently available information on electronic cigarette marketing and sales only collects data on cig-a-likes that the major cigarette and e-cigarette companies sell through conventional channels (such as convenience stores, service stations, large retailers).  Therefore, researchers cannot study how the market share is changing with other electronic cigarette products (such as tank systems) that are predominantly sold through “vape shops.” Information on the full range of products and sales outlets is important to determine how rates of use, perceptions, and social norms vary by the marketing of various types of products.  Detailed FTC reports on electronic cigarette marketing and sales would thus help researchers study changes in sales of various types of electronic cigarette products as a function of marketing. 
Since there is a clear relationship between use and marketing, the information FTC proposes to collect and report would allow researchers to examine changes in use of various types of electronic cigarettes (e.g., cig-a-like compared to mods) as a function of marketing and sales.
Types of advertising media and product placements
Adolescents are exposed to electronic cigarette marketing through multiple channels, including but not limited to television, print media, online promotion, point-of-sale advertising, distribution of promotional items (e.g., clothing or other logo-branded items), motion pictures, television (broadcast, cable and streaming), video games, and event sponsorship. Previous research on cigarettes has shown that adolescent smoking is caused by tobacco marketing and promotion through multiple channels.[8]  The FTC should monitor all of these possible promotion channels, especially those with high-risk of youth exposure, to assure that the impact on use of electronic cigarettes by youth can be adequately assessed.
Specific data on the amounts being spent on various media (e.g., TV, Internet, social media, print) for different population subgroups would be especially helpful because each subgroup uses different kinds of media to varying degrees. Having differentiated information on specific marketing strategies would allow research into how the industry is targeting different subgroups of (potential) smokers (i.e. different age groups, genders, ethnic /racial backgrounds, sexual identities, urban/rural populations etc.). Similarly, data on product placements in TV programming, motion pictures, magazines, and other publications by population subgroup would aid our research because it would allow us to evaluate industry targeting of different subgroups by selective product placements.
It would also be helpful for each company to indicate the top three outlets and top three programs within each media category and outlet where they dedicate the greatest marketing expenditures.  For example, it would be important to have information regarding marketing on a specific TV network or channel (e.g., Comedy Central) or a specific Internet company (e.g., Facebook), as well as programs on those channels. This information will allow us to evaluate what target audiences the companies advertise their products to, and to track how such marketing efforts influence perceptions and use patterns.
Price and price promotions
Price promotions are an important element of tobacco marketing and promotions.  FTC should collect detailed data (not just aggregate costs) on price promotions (including coupons, two-for-one sales, and similar promotions) that reduce the effective price of e-cigarettes and their components, including the same kind of detailed demographics on the target markets as for media advertising and promotion.
The FTC should collect data for each individual electronic cigarette flavor sold by the companies, rather than identify various flavor categories.  These specific data would be essential to our research because the name of the flavor is a form of marketing; when people buy a specific flavor it is important to know not only what type of flavor it is (fruit, candy, alcohol), but also how whether the name of the flavor is particularly appealing to certain demographics. Further, given the relationship between flavors and increased use among youth, it would be important to have specific information that allows us to determine relationships among types of flavors, marketing and use among youth compared to young adults and adults.  
Nicotine content
Similarly, FTC should collect data for every level of nicotine content sold by the companies, rather than identify various ranges of nicotine content.  Similar to the name of  the flavor, the amount of nicotine and how it is communicated (whether in percent or in milligrams) might serve as a form of marketing.  Researchers and regulatory agencies need this information to determine whether some specific level of nicotine might be more appealing.
Specifically, the data on the exact levels of nicotine (rather than on nicotine level ranges) would allow for testing of two competing hypotheses:

  1. Reduced level nicotine products will be associated with reduction in nicotine use. (A randomized clinical trial found that smokers who used very low nicotine level cigarettes smoked fewer cigarettes, had less cravings, and made more quitting attempts.)[9]
  2. Reduced level nicotine products will be associated with greater consumption (smoker compensation). 

Types of devices
In addition, in order to advance regulatory science, it would be helpful to differentiate between refillable and disposable cartridge systems of electronic cigarettes, as well as between different types of electronic cigarettes (perhaps by the amount of liquid it can hold or by the type of battery). Emerging research shows that for some smokers visual similarity of first generation e-cigarettes to cigarettes is an appealing characteristic; other smokers prefer the second generation e-cigarettes precisely because they look nothing like conventional cigarettes.[10] The differences in the way devices look and how they deliver nicotine are important product characteristics that affect who uses them and how they are used.
It would be useful to evaluate how changes in sales of the different types of electronic cigarette devices correspond to changes in uptake of electronic cigarettes among both smokers and non-smokers, but more importantly, to changes in smoking rates.  It would be useful to evaluate whether sales of cig-a-likes (which typically deliver lower levels of nicotine to smokers than more advanced systems)[11] are associated with reduction or increase in smoking.
            Differentiated data on flavors, nicotine strength, sizes, liquid capacity of cartridges, and type of sales would be invaluable to public health research because these specific data would allow us to examine and understand relationships among various factors and usage patterns.  Currently, we know little about market share and use of specific flavors, nicotine levels or types of devices.  As a result, we cannot examine whether specific marketing strategies and sales are related to each other, and how they relate to actual use among youth, adolescents, young adults, and adults.
FTC should require companies to report how they verify customers’ age for Internet sales
Studies show that websites selling electronic cigarettes over the Internet overwhelmingly do not have safeguards in place to prevent purchase by those under 18.[12] Having companies report their activities regarding how they verify age and prevent acquisition of electronic cigarettes by minors (either through sales or give-aways) would be useful to track over time to see if this situation changes or if more stringent regulation actions are required.
FTC should collect state-specific information about electronic cigarette marketing and sales
FTC should collect data on state-by-state sales of electronic cigarettes and related products because state and local tobacco control programs have begun to regulate electronic cigarettes sales and use in the absence of federal regulation.[13]   State-specific information about marketing, sales, price promotions, and give-aways helps inform public health officials and policy makers about policy effectiveness and how the industry responds to certain policies. This information would allow us to examine regional differences in electronic cigarette sales and marketing.  
This information would be valuable in its own right as well as be useful in quantifying the overall relationship between e-cigarette marketing and promotional activity (including price promotions) and use by youth, young adults, and the general population.

[1] Rachel Kornfield et al., Rapidly Increasing Promotional Expenditures for E-Cigarettes, TC ONLINE FIRST, 1 (April 30, 2014).


[3] Rene Arrazola, Tobacco Use Among Middle and High School Students—United States, 2011-2014, 64 M ORBIDITY AND MORTALITY WEEKLY 381, 383 (April 17, 2015).

[4] Dutra and Glantz, E-cigarettes and conventional cigarette use among US adolescents: A cross-sectional study, 7 JAMA PEDIATRICS 610, 610 (July 2014); Adam M. Leventhal et al., Association of Electronic Cigarette Use with Initiation of Combustible Tobacco Product Smoking in Early Adolescence, 314            JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 700, 706 (2015); Thomas A Wills et al., E-cigarette use and willingness to smoke: a sample of adolescent non-smokers, TC ONLINE FIRST, doi:10.1136/tobaccocontrol-2015-052349 (August 2015); Brian A. Primack, et al., Progression to Traditional Cigarette Smoking after Electronic Cigarette use among US Adolescents and Young Adults, JAMA PEDIATRICS ONLINE FIRST, E4-E5 (September 8, 2015); see Graham F. Moore et al., E-cigarette use and intentions to smoke among 10-11-year-old never-smokers in Wales, TC O NLINE FIRST, 10.1136/tobaccocontrol- 2014-052011 (December 22, 2014) (finding e-cigarette use associated with weaker antismoking intentions); see also Andrea C. King et al., Passive exposure to electronic cigarette (e-cigarette) use increases desire for combustible and electronic cigarettes in young adult smokers; see also Rebecca E. Bunnell, Intentions to Smoke Cigarettes among Never-Smoking U.S. Middle and High School Electronic Cigarette Users, National Youth Tobacco Survey, 2011- 2013, Nicotine & Tobacco Research, 6 (2014) doi:10.1093/ntr/ntu166 (finding e-cigarette use among never-smokers associated with intentions to smoke).

[5] US Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General.  Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2012.

[6] Davis RM, Jason LA. The distribution of free cigarette samples to minors. Am J Prev Med. 1988;4(1):21-6.

[7] Tessman GK, Caraballo RS, Corey CG, Xu X, Chang CM. Exposure to tobacco coupons among U.S. middle and high school students. Am J Prev Med. 2014;47(2 Suppl 1):S61-8.

[8] US Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General.  Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, 2012.  For studies of specific media channels, see, for example: Sargent JD, Dalton MA, Beach M, Bernhardt A, Pullin D, Stevens M. Cigarette promotional items in public schools. Arch Pediatr Adolesc Med. 1997;151(12):1189-96. Sargent JD, Dalton M, Beach M. Exposure to cigarette promotions and smoking uptake in adolescents: evidence of a dose-response relation. Tob Control. 2000;9(2):163-8. Slater SJ, Chaloupka FJ, Wakefield M, Johnston LD, O'Malley PM. The impact of retail cigarette marketing practices on youth smoking uptake. Arch Pediatr Adolesc Med. 2007;161(5):440-5.  Tessman GK, Caraballo RS, Corey CG, Xu X, Chang CM. Exposure to tobacco coupons among U.S. middle and high school students. Am J Prev Med. 2014;47(2 Suppl 1):S61-8.  Paynter J, Edwards R. The impact of tobacco promotion at the point of sale: a systematic review. Nicotine Tob Res. 2009;11(1):25-35.

[9] Donny EC, Denlinger RL, Tidey JW, Koopmeiners JS, Benowitz NL, Vandrey RG, al’Absi M, Carmella SG, Cinciripini PM, Dermody SS, Drobes DJ. Randomized trial of reduced-nicotine standards for cigarettes. New England Journal of Medicine. 2015 Oct 1;373(14):1340-9.

[10] Dawkins, L., Kimber, C., Puwanesarasa, Y. and Soar, K. (2015), First- versus second-generation electronic cigarettes: predictors of choice and effects on urge to smoke and withdrawal symptoms. Addiction, 110, 669–677. doi: 10.1111/add.12807.

[11] Farsalinos K. E., Spyrou A., Tsimopoulou K., Stefopoulos C., Romagna G., Voudris V. Nicotine absorption from electronic cigarette use: comparison between first and new-generation devices. Sci Rep 2014; 4: 4133–40.

[12] Williams RS, Derrick J, Ribisl KM. Electronic Cigarette Sales to Minors via the Internet. JAMA pediatrics. 2015;169(3):e1563-e1563.

[13] Lempert  L, Grana R, Glantz S, The importance of product definitions in US electronic cigarette laws and regulations, Tob Control., 2014 Dec 14. pii: tobaccocontrol-2014-051913. doi: 10.1136/tobaccocontrol-2014-051913; Centers for Disease Control and Prevention, Marynak K, Holmes CB, King BA et al., State laws prohibiting sales to minors and indoor use of electronic nicotine delivery systems – United States, November 2014. MMWR Morb Mortal Wkly Rep. 2014 Dec 12,63(49):1145-50.