Vaping Goes Viral: The Role of Commercial E-Cigarette Tweets in Youth E-Cigarette Use Susceptibility

Abstract Introduction Social media (SM) are major marketing platforms for e-cigarette product promotion, particularly among youth. While prior studies have established associations between self-reported SM e-cigarette marketing exposure and youth e-cigarette use susceptibility, the strength of inferences based on these studies is limited by potential biases associated with self-reported measures. We use state-level rates of tweets promoting e-cigarettes as an exogenous indicator of potential exposure to e-cigarette marketing on social media, enabling us to examine the effects of digital promotion on youth susceptibility to e-cigarette use. Methods The Population Assessment of Tobacco and Health Study (2018–2019) data were linked with state-level commercial e-cigarette tweet rates. Tweets were classified as promoting e-cigarette products using machine learning. Monthly commercial tweet rates per 100 000 state residents were linked to respondents. Multivariable logistic regression was used to assess associations between tweet rates and e-cigarette susceptibility, controlling for demographic and behavioral covariates. Results Of 1489 youth aged 14–17 who have not heard or used e-cigarettes, 32.1% reported susceptibility to e-cigarettes. Youth residing in states with commercial tweet rates above the 90th percentile had 63% higher odds of e-cigarette susceptibility (OR: 1.633; 95% CI: 1.099, 2.426), compared to those at or below the median tweet rate. Other associated factors included sexual orientation, cannabis use, having a tobacco user in the home, and being White (vs. Black). Conclusions Greater potential exposure to commercial e-cigarette content on X/Twitter is associated with increased odds of youth susceptibility to e-cigarette use. These findings underscore the need for enhanced regulation and monitoring of SM marketing to mitigate youth exposure and e-cigarette uptake.