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Abstract

Introduction: India is one of the few countries to have banned production, manufacture, import, export, transport, sale, distribution, storage and advertisement of electronic cigarettes (e-cigarettes). With the advent of technology, these product are being marketed extensively on internet despite the ban. Objective: To assess promotion and sales of e-cigarettes on the internet, and social networking sites (SNS); and to assess the levels of awareness regarding e-cigarettes among youth participants and the source of receiving information on e-cigarettes. Methodology: In 2022, a survey was conducted with youth (18-24 years), along with a desk review to identify influencers promoting, and e-stores selling e-cigarettes in India. Further, a content analysis was conducted on the identified influencers and online stores. Results: 370 youth with a mean age of 21.1 ± 1.7 years participated in the survey. 66.6% of participants reported being aware of e-cigarettes through social media. Instagram (46%) was identified as the most popular social networking platform for promoting e-cigarettes. 189 influencers promoting e-cigarettes on Instagram were identified and their posts positively portrayed e-cigarettes (trendy/cool, flavours, hedonic value, features cessation aid and cost-effective). Additionally, 83 e-stores (49 Indian and 34 international) were identified as selling e-cigarettes in India. Findings from content analysis of both influencers and e-stores highlighted issue of international cross-border marketing. Conclusion: To safeguard youth and achieve a path to Tobacco-free generation; there is a dire need for strengthening the monitoring and enforcement of PECA 2019, especially to address international cross-border advertisements and sales of e-cigarettes. Additionally establishing strong reporting violation mechanisms is also needed. Furthermore, educating youth, retailers, policy makers and community via sensitization programs on detrimental effects of e-cigarette use and existing policies related to e-cigarettes in India is crucial.

Keywords

e-cigarettes e-cig influencers internet e-stores social networking sites India vape policy

Background

The global expansion and evolution of tobacco product landscape led to the emergence of novel products like e-cigarettes¹ in 2003.² E-cigarettes or other Electronic Nicotine Delivery Systems (ENDS) are battery-operated, handheld devices that produce inhalable emissions by heating a solution that commonly contains nicotine, a humectant, and flavoring chemical.³ The primary agent of these products is mostly nicotine which is a harmful and highly addictive substance.⁴ These products are commonly known as ‘vape’ and have gained popularity among adolescents and youth for various reasons 5; Impulsiveness, desire to experiment with novel products and their exposure to misleading claims increases adolescent risk of initiating this addiction.^5,6 Additionally, product design, availability in different flavours, perception of being less harmful and being highly addictive have enhanced its appeal among youth.⁶

Scientific evidence reveals vaping adversely affects the cardiovascular system,⁷ impairs respiratory immune cell function and airways in a way similar to cigarette smoking.⁸ Disturbingly, the usage of nicotine containing e-cigarettes among the young population has been associated with chronic bronchitis symptoms. The nicotine in e-cigarette affects the young developing brain development, leading to changes in mood, learning, attention, and impulse control.¹ Additionally, e-cigarettes users are at increased risk of smoking both concurrently and in the future,⁹ thus undermining the progress made in tobacco control efforts in each country.

Globally, governments are acting to safeguard youth from e-cigarettes. Thirty-two countries have banned the ‘sale of ENDS’, and other 79 countries, have implemented legislative measures to regulate ENDS. Twenty two countries including India, have completely banned the advertising, promotion and sponsorship of ENDS.⁹ In 2019, the Ministry of Health and Family Welfare, Government of India enforced “Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement) (PECA) Act, which covers all forms of e-cigarettes¹⁰ including all “Electronic Nicotine Delivery Systems, Heat Not Burn Products, e-Hookah”. The Act prohibits any advertisement or sale of e-cigarettes across all media, including electronic media, internet, websites, or social media with violations subject to penalities. Section 4(ii) prohibits individuals from participating in any advertisement that directly or indirectly promotes the use of e-cigarettes. Additionally, Section 4(i) bans both direct and indirect selling or distribution of e-cigarettes,including free samples. Violations of the PECA are penalised.

In 2022 the Indian government enforced “The Guidelines for Prevention of Misleading Advertisement and Endorsements for Misleading Advertisements” which completely prohibits advertisement of banned products. Issued by the Central Consumer Protection Authority [CCPA], Ministry of Consumer Affairs, these guidelines prevent false or misleading advertisements and endorsements. They apply to both an advertiser (includes a manufacturer and service provider) and advertising agencies, which provide advertisement design and production services for a fee. Section 9 of guidelines, prohibits advertising of goods banned under any law and Section 6 prohibits surrogate advertisement or indirect advertisement of banned product. The guideline specifically regulates endorsers as outlined in [section 2(f)]. Restrictions on advertisements also apply to endorsers [section 3(b)]¹¹ and Section 21 of the Consumer Protection Act 2019¹¹ prescribes penalties of non compliance.

Despite the enabling legislative environment studies conducted within two-three months of the enactment of PECA 2019 reported, availability of e-cigarettes in major Indian cities including Bengaluru, Chandigarh, Dehradun, Delhi, Indore, Kolkata, Ludhiana, Raipur, and Ranchi in 2020.¹² E-cigarettes were reportedly sold through retail shops^13,14 underground markets,¹⁵ online.¹⁶ In today’s world, the internet including social media is acting as a powerful conduit for tobacco marketing (including e-cigarettes) and creates a tobacco-permissive context, that is influential to youth. In India, in 2019, two-thirds of 504 million active internet users were between the ages of 12 and 29 years¹⁷ and during the pandemic, there was an uptick in the usage of the internet especially by youth and the percentage of internet users in India rose by 10.2% during the COVID.¹⁶ Immediately after PECA 2019 was enforced, the COVID pandemic hit the globe and shifted the entire marketing and delivery of many commodities including e-cigarettes to online platforms and making home deliveries pervasive.¹⁸ Thus, based on the rationale of the apparent availability of e-cigarettes in India even after being banned and the changing environment of marketing to online mode; this study was conceptualised employing scientific methodology to; 1) assess the online promotion and sales of e-cigarettes on social media, and, 2) assess the levels of awareness regarding e-cigarettes among youth participants and its sources of information.

Methodology

Study Design

A cross-sectional study, using mixed methods (both primary and secondary methods) was conducted (Figure S1). The primary research methods included an online survey with youth aged 18-24 years to identify influencers promoting e-cigarettes and online stores selling these products. E-cigarettes were referred to as all forms of Electronic Nicotine Delivery Systems, Heat Not Burn Products, e-Hookah and the like devices, by whatever name called and whatever shape, size, or form as defined in PECA 2019. In addition, secondary research undertaken included a desk review by the study team, to identify e-stores and influencers on the most common SNS platform. A desk review is a method that involves analysing and summarizing previously published studies, reports, articles and other relevant material. Content analysis of identified influencers and e-stores through the survey and the desk review was undertaken.

Sample Size

The sample size to survey youth was calculated taking into account the Population Census of India 2011.¹⁹ A formula was used to calculate sample size as per the Census report 2011, 19.4% of the Indian population is between the age group of 15-24 years, thus the population size calculated to be n = 233,368,000, anticipated frequency at 50, margin of error (5%) and confidence level (95% or 1.96) were considered. Based on the above calculation, the sample size was calculated to be 384, considering non-response of 10%.

Sampling

A convenience, snowball sampling technique was used to recruit youth (18-24 years) from all geographical regions of India i.e., North, West, East, South, Central and North-East as classified under NSSO²⁰ and Global Adult Tobacco Survey.²¹ The initial step included approaching youth through the existing academic institutes²² and our previously established networks of colleges from different regions of India, further contacting other youth from their region. Using this approach, 10 youth from every state and 5 from every union territory, across India were included for geographical representation. Written informed consent was taken from participants before survey administration.

Data Collection

The data was collected using a self-administered ‘Google form’ from June-September 2022. The survey included 8 questions band collected information on common influencers/people promoting ENDS and e-stores selling/promoting e-cigarettes Vapes, vaporizers, vape pens, hookah pens, electronic cigarettes (e-cigarettes or e-cigs), e-cigars, and e-pipes on various SNS. The survey was pre-tested with youth (n = 10) to establish face validity. Suggestive changes were incorporated and a modified survey was used for the main study. Youth who participated in pre-testing were not included in the main study.

To develop a comprehensive list of stores selling e-cigarettes online, a desk review was conducted by researchers (n = 2) independently, based on an internationally approved methodology.²³ The search was conducted from June 2022 to July 2022 on Google using the following keywords/Medical Subject Headings (MeSH) terms: ‘e-cigarette,’ or ‘e-cigarette,’ or ‘e-cig,’ or ‘e-cig,’ or ‘ecig,’ or ‘ecigs,’ ‘electronic cigarette,’ or ‘electronic cig,’ or ‘electronic nicotine delivery system,’ ‘ENDS’ or ‘vape,’ or ‘vaper’ or ‘vaping’ AND ‘sale’ AND ‘India’. The first ten pages of each search were reviewed to capture, the maximum number of stores selling e-cigarettes online in India.

To identify influencers, researchers (n = 2) independently searched for public profiles (content on their page is visible to all) of influencers on the most common SNS platforms. The influencer search was conducted using hashtags and keywords associated with pro-e-cigarette products like #vape, #vapelife, #vapenation, #e-cig, #ecigs, #electronic cigarette, and #ENDS as reported in similar studies.²⁴ Desk review for influencers was only limited to Instagram, as it was the highest reported SNS by the participants via survey. A verified account on Instagram indicates that it has been confirmed as the authentic presence of the public figure, celebrity or brand it represents by providing a blue check next to the account name on the profile.

Content Analysis

Content analysis of the identified influencers and e-stores, promoting or selling e-cigarettes was conducted by researchers (n = 2) from June-September 2022 using standardized protocols and a coding sheet. Any discrepancy was resolved by discussion with the third researcher. A coding sheet was developed based on national and international literature to code e-stores, influencers’ account, and e-cigarette posts of influencers.^25,26 The detailed list of variables included in the content analysis for e-store and influencers was provided as Table S1.

Data Analysis

Collected data from the survey and desk review was cleaned, coded, entered in Excel, and analysed via SPSS version 22.²⁷ Descriptive statistics including mean, percentages and chi-square test were applied.

Results

This section describes the findings from the survey and content analysis emphasing on influencers and their accounts.

Survey Findings

A total of 384 youth were approached for the survey and 370 participants from all states (n = 28) and union territories (n = 8) of India were included in this study, highlighting 96% response rate. The remaining (n = 14) participants, either did not provide consent or were removed from analysis due to incomplete information. The mean age of participants was 21.1 ± 1.7 years. 58.6% of participants were males and 41.4% were females. Zonal representation of participants included 22.2% from North-East zone; 21.9% from North zone; 17.7% from South zone; 13.8% from East zone; 12.2% from Central and 12.2% from West zone of India. This difference in participants’ representation was due to the difference in the number of states and union territories under each zone.

Survey findings revealed, more than half (55.4%) of the participants were aware of e-cigarettes (vapes, vaporizers, vape pens, hookah pens, electronic cigarettes, e-cigars, and e-pipes). Females (62.7%) were found to be more aware of e-cigarettes than males (50.2%) (P value = .017). Of this, 67.3% of participants had heard about e-cigarettes through social media, with Instagram receiving the highest percentage (46%), followed by Facebook (23%), Telegram (7%), Twitter (6.5%), Pinterest (5%), Reddit (4.2%), LinkedIn (3.4%), YouTube (1.9%) and Tumblr (1.5%). Invalid responses were given by the remaining 1.5% of participants.

The majority of participants (93.2%) were unaware of the PECA 2019, which bans e-cigarettes in India. None of the participants knew about all the legal provisions under the Act. Only a few (n = 14) participating youth were aware of the PECA 2019 legal provisions. (Figure 1)

Figure 1.

Awareness of legal provisions under PECA 2019.

The findings also reveal that among the participants who were aware of “The PECA, 2019; only 20.0% were informed about the different penalties under the act.

Content Analysis: Influencers

A total of 189 influencers on Instagram were identified from the survey and desk review promoting e-cigarettes on their Instagram accounts. More male influencers (68.3%), than female influencers (29.1%) were found promoting e-cigarettes. Out of 189 influencers, only 1.1% were Indian and others were from countries like, The United States of America (18.6%), Indonesia (15.9%), Italy (7.4%), United Kingdom (4.9%), Germany (2.1%), Australia (2.1%), Brazil (1.6%), Canada (1.6%), Philippines (1.6%), Morocco (1.6), France (1.6%), Spain (1.6%), South Africa (1.1%) and other countries (7.0%). For 30.2% of the influencers, information on nationality was not available. Among the identified influencers, only 2.1% had a verified account which was from the United State of America and Indonesia.

Influencers Followers

The majority (90%) of influencers were micro-influencers (having 1000-100,000 followers); 7.9% were macro-influencers (having 100 000- 1 million followers) and only 2.1% were reported as mega influencers (with more than one million followers). The total reach of the identified 189 influencers was approximately 71 million. An Athlete from USA, with 32.8 million followers on Instagram had the highest followers among our identified influencers (Table 1). The two identified Indian influencers, “A fashion model” and “a video creator” had 13.6 K and 11K followers, respectively.

Table 1.

Top 10 influencers based on the number of followers.

Sl. no	Profile of the influencer^a	Country	Number of followers on the profile^b	Date of access
1	A professional athlete	USA	32.8M	21/07/2022
2	A community page	USA	3.7M	05/07/2022
3	A vape enthusiast	USA	2.5M	21/06/2022
4	A public figure	Italy	1.1M	23/06/2022
5	A musician	Indonesia	968K	03/07/2022
6	A personal account	USA	442K	21/06/2022
7	A blogger	Italy	298K	23/06/2022
8	A personal blogger	Italy	239K	28/06/2022
9	An artist	Indonesia	235K	21/06/2022
10	A personal account	Japan	210K	07/07/2022

^aCoded names are presented to maintain ethical standards.

^bNumber of followers are as on date of access.

Influencers’ Recent Post

Recent posts (the first post on their account on the date of access) of each influencer were considered and hence a total of 189 posts were analysed. All the influencers had posted the posts themselves. Most of these posts (77.2%) were in the form of photos whereas 22.8% were videos.

Brand Endorsement and Paid Partnership

In 81% of posts, the brand name of the e-cigarette was visible. The majority of the e-cigarette brands were from China, USA, UK and none from India. Moreover, the majority (99.5%) of the posts did not declare a paid partnership and only, 5% of posts had declared paid partnership by tagging a brand on their post.

Presence of Warnings

21.2% of posts had some warnings. The commonly reported warnings were related to age (18+ adults only; 21+ years only; prohibited the use or sales to minors (+18/+21 years) and other related to nicotine as a harmful substance (this product contains nicotine and nicotine is an addictive chemical). Some emphasised both age and nicotine (you must be of legal age to vape; prohibited under 18 years, may contain nicotine; etc.) and 2.5 % had other. (Table 2)

Table 2.

Types of health warnings on influencers’ posts.

S. no	Health warning	N (%)
Age-related
1	Prohibited for 18, only for 18+ years	14 (35)
2	Only for 21+ years	2 (5)
3	Only suitable for 18+/21+/prohibited under 18/21	4 (10)
4	You must be of legal age to vape	3 (7.5)
5	Other (the association and sale of moztro coils with minors is prohibited)	1 (2.5)
Nicotine related
6.	This product contains nicotine and nicotine is addictive	16 (40)

Portrayal of e-cigarettes

Overall, 69.8% of influencers presented e-cigarettes as positive, and 30.2% gave e-cigarettes a neutral image. None of the influencers posted negative effects of using an e-cigarette. Out of all the posts that portrayed e-cigarettes positively, 47.7% showed them as trendy or cool; 6% of influencers mentioned various flavours; 29.5% highlighted their hedonic value; and 12.1% highlighted technical/aesthetic features of e-cigarettes, 1.5% depicted it as healthy/safe/as a cessation aid, while only 0.7% depicted it as cost-effective (Table 3).

Table 3.

Portrayal of post promoting e-cigarettes.

S. no	Positive portrayal	^aN (%)
1	Trendy/cool	63 (47.7)
2	Flavours	8 (6)
3	Hedonic value	39 (29.5)
4	Features/specification	16 (12.1)
5	Cessation aid	2 (1.5)
6	Cost effective	1 (0.7)
7	Others (unboxing, picture, promotional event)	9 (6.8)

^aMultiple responses for each post.

Content Analysis: E- Stores Selling E-Cigarettes

A total of 83 e-stores (national: 49 and international: 34) were identified as delivering e-cigarettes in India. 61.4% of e-stores were identified on Google, followed by Instagram (35%) and Facebook (3.6%). Among Indian e-stores, 48.9% were established after 2019. Out of the total e-stores, 78.3% exclusively sold e-cigarettes, 6% with cannabis and 15.7% with fashion products.

Age Verification

39.8% of e-stores required customers to verify their age. The most common verification standards for age were ‘for 18+ years’ (42.5%), ‘for 21+ years’ (45.6%). A few other verification standards were: ‘for 19 years and above’ (6%); ‘Are you of legal smoking age? [yes/no]’ (3%); ‘not for sale to minors (3%). It was also found that most stores required just a self-verification (tick or selecting check box) while entering or purchasing from an e-store. Only one online from the United States of America had a provision for a ‘Photo ID check’ for those above 18 years while purchasing or delivering e-cigarettes.

Product Flavours and Nicotine Strength

E-cigarettes are being sold in many flavours in e-stores. Fruit/dessert/candy (83.1%) was the most prominently advertised flavors followed by Menthol (67.5%), Tobacco (57.8%), and Alcohol/drinks (49.4%). The nicotine strength of e-cigarettes reported on e-stores ranged from 0.5- 70 mg/mL. 53% of e-stores were found selling products with nicotine strength between 0-50 mg/mL and only 3.6% of e-stores had products with nicotine strength higher than 50 mg/mL. However, the nicotine strength of 43.4% of vending sites was not available.

Portrayal of Electronic Cigarettes on E-Stores

14.5% of e-stores portrayed e-cigarettes as positive, 77.1% as neutral and 8.4% as negative. The positive posts made claims on healthiness (75%), cessation aid (33.3%), hedonic value (satisfaction about taste/flavour) (8.3%), cost-effectiveness (8.4%), and others (8.4%). (Table 4). The stores which highlighted negative aspects of e-cigarettes included their association with various diseases like heart disease, and not being safe to use by specific age groups like pregnant women, children etc. The majority (81.9%) of the e-stores did not declare any kind of health/other claims on their websites.

Table 4.

Health/other claims made by e-store on websites.

S. no	Model claims	N^a (%)
1	Healthiness	9 (75)
2	Cessation aid	4 (33.3)
3	Hedonic value (satisfaction about taste/flavour)	1 (8.3)
4	Cost-effective	1 (8.3)
5	Others	1 (8.3)

^aMultiple responses analysis.

Discussion

Our study employed a robust scientific methodology to assess strategic use of the internet for e-cigarette marketing. The comprehensive analysis revealed a landscape characterized by the widespread promotion and sale of e-cigarettes proliferate across various social media platforms. This trend is facilitated by two primary channels: the endorsement and dissemination of e-cigarettes by influencers, and the establishment and operation of e-commerce stores exclusively dedicated to marketing these products. Through these avenues, the visibility and accessibility of e-cigarettes are significantly amplified, contributing to their widespread presence within online communities. Despite the ban, 26% of Indian youth have been exposed to e-cigarette marketing through online platforms.²⁸ These findings corroborate our study findings, as 55.4% of youth in our study reported having heard of e-cigarettes through Instagram which is a youth-centric SNS platform. Similar results have been reported on how social media especially Instagram is used to promote e-cigarettes among Indonesian youth.²⁹ It is observed that ‘Facebook’ and ‘Instagram’ have prohibited e-cigarette brands from directly promoting or advertising on their platforms, nevertheless focus has shifted to utilising influencers for promotion.³⁰ This is worrisome as influencers hold significant potential to channel information across a large number of followers on social media, are extremely persuasive, and also act as role models for youth.³¹ Our findings also indicate, that a significant number of influencers promoting e-cigarettes on SNS hail from foreign countries such as the United States, Indonesia etc. This raises concerns about the ‘cross-border marketing’ of prohibited products which has been reported in the literature.³²

From a policy perspective, any person, who takes part in any advertisement that directly or indirectly promotes the use of the e-cigarette, is liable under the PECA 2019 for violating section 4(ii). Therefore, influencers identified in this study on Instagram promoting the use of e-cigarettes may be held liable under section 7 of PECA 2019. In addition, influencers or endorsers would also be violating Section 9 and liable under Section 21 of the Consumer Protection Act, 2019³³ for endorsing e-cigarettes or taking part in surrogate advertisements and indirect advertisements of e-cigarettes. Also as per the ‘Information Technology Act, 2000’ under which, the host of website’s, would be liable (although the host may have a different liability threshold given its intermediary status under the Information Technology Act, 2000).

In the present study, only 0.5% of the influencers declared paid partnership, although the Guidelines for Prevention of Misleading Advertisements and Endorsements for Misleading Advertisements 2022¹¹ place additional due diligence requirements for endorsers, requiring them to represent products based on adequate information about, or experience with the product. Endorsers are also required to disclose material connections between the endorser and the trader/manufacturer/advertiser.

In addition, like many others,²⁹ our study findings also reveal that influencers promote e-cigarettes as a ‘trendy/cool, flavours, hedonic value, cessation aid and cost-effective’, using features designed to create an illusion in the fragile mind of the youth. Experiment studies have shown that viewing e-cigarette Instagram posts increases positive attitudes toward e-cigarettes and intentions to vape^34,35 and these impacts become stronger when endorsed by a celebrity than a non-celebrity.³⁵ Considering the impact of influencers, the Department of Consumer Affairs, Government of India in January 2023 announced new guidelines for social media influencers. These guidelines require influencers to disclose promotional content by the Consumer Protection Act, 2019. Failing to comply with these guidelines could result in a fine of up to $12,300 (1 million Indian rupees) with a potential for increased penalties for repeat offenders, for upto $61,600 (5 million Indian rupees) to the influencer. This move by the government of India is commendable, as it addresses the policy gap and provides protection for consumers against misleading advertisements facilitated by the persuasive power of influencers.^36,37 However, enforcement of these guidelines is the need of the hour to protect Indian adolescents and youth.

The study findings showed the number of e-stores (national and international) selling e-cigarette. Moreover, the Indian stores selling e- cigarette are liable under Section 7 of PECA (2019)¹⁰ for violating Section 4(i) which prohibits selling or distributing e-cigarettes. Our study findings also uncover the delivery of e-cigarettes to India by international stores, highlighting the issue of cross-border interference. While the Act applies to sales across India and includes provisions against ‘offers and exposures’ for sale; therefore, its provisions can be interpreted to include a prohibition on sales irrespective of the medium, including sales on websites and social media. Clarifying the provisions of the Act in this regard would be a step towards curbing the sale of e-cigarettes in India. Countries such as Singapore,³⁸ Panama³⁹ and Portugal⁴⁰ categorially prohibit the digital or internet sale of electronic cigarettes. Similar measures should be considered in India as well. Additionally, there is a need to develop robust violation reporting mechanisms across India and to implement appropriate actions in response.

The violation of sections of the given policy or Act in the present study highlights the need for stringer implementation and enforcement. Legislative measures are evidenced to be effective by the recent report of 75 countries. The countries with the most restrictive e-cigarette policies (compared to no Regulatory Policies) had 0.6 times lower odds of being current e-cigarette users (aOR .6, 95% CI .6, .7).⁴¹ To effectively enforce the ban on the sale and advertisement of e-cigarettes in India, it is imperative to completely prohibit exposure to advertisements and promotional content related to e-cigarettes on these platforms. PECA 2019 may provide clarification on the criteria for determining the electronic publication of advertisements in India, including instances where advertisements are deemed to be electronically published in India even if they did not originate domestically. Singapore’s Tobacco Control Act includes a similar provision that restricts advertisements generated outside Singapore to not be accessible/available within Singapore of prohibited products.⁴² Similarly, Argentina, prohibits cross-country advertisements, especially for social media posts that originate from other countries.^43,44

The study highlights, the lack of awareness among youth study participants about PECA, 2019. It is crucial to raise awareness among youth(who are vulnerable to the predatory tactics of the tobacco industry), retailers, policymakers and the wider community. In India, school health interventions are effective for preventing and reducing tobacco use,⁴⁵ indicating the need for similar efforts targetting e-cigarettes. The existing ongoing national programs like the School Health Programme under Ayushman Bharat,⁴⁶ National Tobacco Control Programme⁴⁷ and Tobacco Free Educational Institute Guidelines (TOFEI)⁴⁸ provide opportunities for sustaining this effort. Moreover, the Ministry of Health and Family Welfare has launched several public service announcements (PSAs) such as Dhuan (2008, 2009), Mukesh (2011), Heartbreak (2011), Sunita (2014), etc.^49,50 on smoking and smokeless tobacco. PSAs have been found effective in many countries^51-53 and thus a similar national-level public awareness campaign on e-cigarettes and provisions under PECA 2019 could be an effective solution.

A few caveats require mention, other social networking sites for example, Facebook, Twitter etc were not explored. In addition, data mining techniques were not utilized in our study but could be explored in future research. The use of convenience sampling limits the generalisability of findings.

The rampant marketing of e-cigarettes has the potential to reverse the progress made in tobacco control efforts in India, consequently calling for strong actions to be taken to ensure the implementation of the provisions of PECA 2019. This includes the establishment of an Inter-Ministerial committee, stringent enforcement including international borders (by customs authorities), and digital (cyber) enforcement. Enforcement agencies should identify violators and direct social media platforms/sites to remove content that violates Indian laws, ensuring that such content is not accessible to the Indian audience. A step forward could be to notify more authorized officers, sensitize law enforcers officials about the restrictive environment and the potential violations perpetrated by the e-cigarette industry, social media sites/platforms, and endorsers/influencers. A sytematic research using unique modern cutting-edge fusion techniques (such as combining text or images) to identify the e-cigarettes sales or trade on social media.⁵⁴

Conclusion

Despite the nationwide ban in India, e-cigarettes are still readily accessible to the country’s youth, which poses a threat to achieving a tobacco-free future generation. There is an urgent need to strictly enforce PECA 2019 and the Guidelines for Prevention of Misleading Advertisements and Endorsements for Misleading Advertisements 2022 to comprehensively prohibit marketing, promotions and sale of e-cigarettes and establish a mechanism for reporting violations to better protect public health. Additionally, as highlighted by our study findings, despite robust national policies, the marketing, advertising and promotion of e-cigarettes continue to reach young people. It is imperative to empower youth, policy makers, retailers and communities through national-level public awareness campaigns and school health programs that raise awareness on the detrimental effects/dangers of e-cigarette use and the provisions of PECA 2019. Hence, to protect our future generations, both stringent enforcement policies and youth prevention efforts are needed.

Supplemental Material

Supplemental Material - Unveiling the Digital Landscape of E-Cigarette Marketing in India: Evidence from Mixed Method Study

Supplemental Material for Unveiling the Digital Landscape of E-Cigarette Marketing in India: Evidence from Mixed Method Study by Deepika Bahl, Shalini Bassi, Nishibha Thapliyal, Kashish Aneja, Praveen Sinha, and Monika Arora in Tobacco Use Insights.

Footnotes

Acknowledgments

The authors gratefully acknowledge Bloomberg philanthropies for their generous support of this activity. However, Bloomberg Philanthropies was not involved in any aspect of this study or writing of this manuscript

Author Contributions

MA, DB, SB conceptualized the study. DB, NT contributed to study administration, data collection and data management. DB, SB and NT contributed to interpretation of study findings. The content analysis was undertaken by NT and DB. DB, SB and NT drafted the manuscript and revised as per inputs received from other authors. MA, PS, KA reviewed the manuscript critically for intellectual content. All authors reviewed and approved the final manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval and Consent to Participate

The study was approved by the PHFI’s Institutional Ethics Committee (TRC-IEC 490/22). All data was collected in accordance with relevant guidelines and regulations. Written, informed consents were obtained from all participants in the study. Consents forms were approved by PHFI’s Institutional Ethics committee (IEC). A participant information sheet (PIS) was also provided to all participants along with the informed consents. The forms included an age-appropriate description of the study in layman terms, potential risks and benefits, confidentiality and anonymity of survey responses, gave them alternative choice to not participate in the study at any given point during the study and information on the Principal Investigator with the contact information. Participant’s confidentiality was protected in several ways. Participants were assigned a unique subject identification number and only this number was used to identify survey responses. Personal data was stored separated from the study data and the key linking personal identifying information and subject identification number is kept in separate password protected file. All responses are kept in a locked file cabinet in secure, locked data management facilities in our office. All study staff maintained data in compliance with guidelines and rules of Indian Council of Medical Research (ICMR) Ethical guidelines. In addition, all staff completed the Good Clinical Practice course offered by National Drug Abuse Treatment Clinical Trials Network (NDAT CTN).

Supplemental Material

Supplemental material for this article is available online.

DISCLAIMER

DisclaimerThe work represents the personal opinion of the author(s) and not that of the organization(s) for whom they work.

Data Availability Statement

Data is available on reasonable request. As per our Institutional data sharing policy, prior approval is required from the Research Management Committee (RMC) and the principal investigator (PI) of the study. De-identified data can only be shared after approval of the request.*

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Supplementary Material

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Unveiling the Digital Landscape of E-Cigarette Marketing in India: Evidence From Mixed Method Study

Abstract

Keywords

Background

Methodology

Study Design

Sample Size

Sampling

Data Collection

Content Analysis

Data Analysis

Results

Survey Findings

Content Analysis: Influencers

Influencers Followers

Influencers’ Recent Post

Brand Endorsement and Paid Partnership

Presence of Warnings

Portrayal of e-cigarettes

Content Analysis: E- Stores Selling E-Cigarettes

Age Verification

Product Flavours and Nicotine Strength

Portrayal of Electronic Cigarettes on E-Stores

Discussion

Conclusion

Supplemental Material

Supplemental Material - Unveiling the Digital Landscape of E-Cigarette Marketing in India: Evidence from Mixed Method Study

Footnotes

Acknowledgments

Author Contributions

Declaration of Conflicting Interests

Funding

Ethical Approval and Consent to Participate

Supplemental Material

DISCLAIMER

Data Availability Statement

References

Supplementary Material