Examining Tobacco-Related Social Media Research in Government Policy Documents: Systematic Review

Abstract

Background

Social media data have been used to describe tobacco industry marketing practices, user experiences with tobacco, and youth-oriented protobacco content.

Objective

Examine the extent to which tobacco-related social media research is cited in government policy documents.

Search Methods

Peer-reviewed tobacco-related social media studies were searched for on Web of Science, PubMed, and other databases from 2004 to 2022. The DOI number for each identified article was then used to search the Overton database to find policy documents citing such research. A secondary, manual search of national and international governmental agency websites was also conducted.

Selection Criteria

Documents were included in this study if they were tobacco-related, written in English, cited social media research in the document text and reference section, and were published by a governmental office or agency.

Data Collection and Analysis

The analytic sample consisted of (n = 38) government policy documents, and were coded for content themes, agency type, document type, and subsequent citations.

Main Results

When this research was utilized, it was often in the context of highlighting tobacco industry marketing practices, bringing attention to an issue (eg, youth e-cigarette use), and/or describing how social media platforms can be used as a data source to understand tobacco-related attitudes and behaviors. Agencies that often cited this research were the WHO, FDA, and CDC. The document types included research reports, policy recommendations, industry guidance, legal complaints, and practice-based recommendations.

Conclusions

Tobacco-related social media research has been utilized by government agencies in the last decade to guide the policy process.

Implications

Tobacco-related social media research has been used in government policy documents to detail tobacco industry marketing and bring attention to youth exposure to protobacco content online. Continued surveillance of social media may be necessary to track the changing tobacco landscape.

Introduction

Tobacco use remains the leading cause of preventable morbidity and death worldwide.¹ Tobacco control researchers have examined data from social media to describe tobacco industry marketing practices,² user experiences with tobacco products,^3,4 and youth-oriented protobacco content online.⁵ However, the extent to which this body of research has been used by government agencies to develop evidence-based policy documents has gone unexamined. Governmental offices and agencies at the state, federal, and international levels develop evidence-based policy documents to alert public health researchers, practitioners, and community stakeholders about emerging health issues.⁶ Evidence-based policy documents, like the Surgeon General’s Advisory on social media and youth,⁷ often summarize the literature to support clinical, intervention, and policy recommendations. Congressional testimony, legal briefs, and agency rulings from governmental offices are the kinds of government policy documents that use research to outline public health concerns and propose legal protective measures.⁸

Previous reviews have documented the themes and promotional strategies used in tobacco-related marketing content on social media,⁹ and methodological approaches used to glean such insights, such as machine learning approaches.¹⁰ One systematic review and meta-analysis showed that participants exposed to tobacco content on social media, compared to those unexposed, were more likely to report tobacco use behaviors.¹¹ However, no reviews to date have shown how tobacco-related social media research has been used to inform policy. In this study, the specific context in which tobacco-related social media research was cited in government policy documents was described. Future areas of research and actionable insights are offered to guide tobacco control researchers, policymakers, and public health advocates.

Methods

Search Strategy

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were used in this study. Informed by a past systematic literature search,¹² the following terms were used to identify peer-reviewed tobacco-related social media research: Tobacco OR cigarette OR cigarillo OR cigar OR e-cigarette OR e-cig OR smoking OR vape OR vaping AND (a social media-related term, such as) Social media OR TikTok OR YouTube OR Instagram OR Facebook OR Twitter OR digital marketing OR online marketing OR online promotion. The literature search was conducted for peer-reviewed original research written in English and published between 2004 and 2022, using online databases: PsycINFO, PubMed, Communication Source, and Web of Science, with an additional search of Tobacco Regulatory Science, which was excluded from the online databases. The period beginning with 2004 was selected because Facebook, one of the earliest and most popular social media platforms, launched that year. Reviews, commentaries, and editorials were excluded. This search identified (n = 256) peer-reviewed empirical articles related to tobacco and social media.

Overton software was used to search for policy documents published by governments, intergovernmental agencies, and nonprofit research centers.¹³ Past research has reliably used Overton to track research citations in policy documents.¹³ Digital Object Identifiers (DOIs) from the identified list of peer-reviewed articles were used to search through the Overton database. Overton excludes policy documents from national agency websites that require users to create an account or monographs without a DOI. As such, a manual search was performed across national agencies’ websites for reports and policy documents that Overton may have excluded.¹⁴ The World Health Organization (WHO) was included in this search, as it is the leading international health agency.¹⁵ Additional agency websites included the US Food and Drug Administration (FDA), Federal Trade Commission (FTC), National Institutes of Health (NIH), Center for Disease Control and Prevention (CDC), Department of Health and Human Services (which includes the Office of the Surgeon General), the Federal Register, and the National Academies of Sciences, Engineering, and Medicine (NASEM). The terms related to tobacco and social media described earlier were then used to search each government agency’s website.

The focus of the governmental policy document search was on federal agencies that define and determine tobacco-related policy in the United States. International health agencies (including foreign ministries of health) and U.S. state policy documents were included in the analysis, if they were identified in the Overton search. A keyword search of social media terms was used to cross-validate all the policy documents, to confirm the presence of tobacco-related social media research, for inclusion in the analytic sample.

Inclusion and Exclusion Criteria

To be included in the analytic sample, policy documents had to be (1) tobacco-related (ie, described a tobacco-related product, policy, or behavior), (2) published by a governmental body or agency, (3) included text where social media research was cited (ie, the research was used in context), (4) included one or more citation(s) of peer-reviewed tobacco-related social media research, and (5) written in English. Two members of the research team reviewed each policy document to confirm it met the criteria for inclusion.

Coding Procedure

A codebook was developed through an inductive process by three members of the research team. Each code was developed using excerpts from the documents until saturation was achieved. The inductive process resulted in seven thematic codes that encompassed the variety of contexts where social media research was used in government policy documents, including: (1) intervention (ie, research was used to support or describe tobacco-related programs and/or interventions), (2) attention to an issue (ie, research was used to bring attention to a tobacco-related problem like youth exposure to protobacco content), (3) user experiences (ie, research that reported reasons for use, user-generated content, and/or user commentary on tobacco products), (4) tobacco industry marketing (ie, research that documented marketing practices, promotions, and/or product packaging), (5) policy advocacy (ie, research that was used as a tool to advocate for or against regulatory actions or laws), (6) protobacco (ie, research that documented positive portrayals/sentiment of tobacco use on social media), and (7) methods (ie, social media was described as a data source to understand tobacco-related phenomena). Each code was mutually exclusive; each government policy document could contain multiple themes. Illustrative excerpts from government policy documents were provided.

All policy documents (n = 38) were triple coded. Coders were trained on the contents of the codebook and were instructed to place a “1” in the cell indicating the presence of a theme, or a “0” in the cell if a theme was absent. Percent agreement was computed for each variable in the dataset, with an average agreement of 76%. Agreement was considered almost perfect for the themes of Intervention (95%), and Policy advocacy (89%), considered substantial for Tobacco industry marketing (76%), Protobacco (76%), and User experiences (71%), and considered moderate for Attention to an issue (63%) and Methods (58%).¹⁶ Discrepancies were resolved by group consensus.

Each government policy document was coded by document type, reflecting (1) research reports (eg, a comprehensive review document), (2) legal complaints (eg, a court filing or complaint against a company), (3) industry guidance (eg, premarket warning letter or agency ruling), (4) practice-based recommendations (eg, information for health communication campaigns or workshops), or (5) policy recommendations (eg, tobacco control strategy, congressional testimony). To assess the scholarly impact of tobacco-related government policy documents, Google Scholar was searched to identify the number of citations each government policy document received.

Results

There were 56 unique tobacco-related policy reports identified in the Overton search and available for download from government and/or agency websites (Figure 1). The manual search of government and agency websites identified 14 additional unique reports. Excluded items were from private nonprofit research centers or think tanks (n = 15), unavailable in English (n = 7), or without text that cited social media research (n = 10). There were (n = 38) documents in the analytic sample.

Figure 1.

PRISMA diagram of government policy documents citing social media research published between 2004 and 2022.

Themes

The most prevalent themes were Tobacco industry marketing (n = 29, 76.3%) and Attention to an issue (n = 26, 68.4%), followed by Methods (n = 18, 47.4%) and User experiences (n = 13, 34.2%). Less observed themes included Protobacco (n = 6, 15.8%), Policy advocacy (n = 5, 13.2%), and Intervention (n = 4, 10.5%; see Table 1).

Table 1.

Codebook of context themes and prevalence of themes describing how tobacco-related social media research was used in government policy documents from 2004 to 2022 (n = 38)

Theme	Description	n (%)
Tobacco industry marketing	Refers to social media research that documented tobacco industry marketing practices, promotions, or product packaging (including promotion of new and emerging products, flavored products, unique product features, use or lack of health warnings, use or lack of age restrictions, etc.)	29 (76.3%)
Attention to an issue	Refers to social media research that was used to help describe a tobacco-related problem (eg, exposure to tobacco-related content on social media is associated with youth appeal and use, normalization of tobacco use)	26 (68.4%)
Methods	Refers to using social media platforms as a data source to examine tobacco-related phenomena	18 (47.4%)
User experiences	Refers to social media research that documented user experiences with tobacco products (eg, users report injuries from devices online, users share selfies with products, users post reasons for tobacco use, such as perceived health benefits)	13 (34.2%)
Protobacco	Refers to social media as a protobacco environment (eg, positive sentiment of tobacco use)	6 (15.8%)
Policy advocacy	Refers to social media research and/or social media platforms (eg, Twitter) used as a tool to advocate for or against regulatory actions or changes to the law	5 (13.2%)
Intervention	Refers to social media research that was used to deliver a tobacco-related intervention and/or program (eg, online cessation groups, prevention programs, health campaigns)	4 (10.5%)

One policy document coded as Tobacco industry marketing (n = 29) described a variety of marketing practices found on social media:

The tobacco industry uses websites and social media to market products, communicate with customers, improve corporate credibility, host smoking interest groups, promote smoking-friendly locations, and oppose evidence-based tobacco control strategies.^17(p.9)

One policy document coded as Attention to an issue (n = 26) described how novel product designs may have increased tobacco product appeal, susceptibility, and use among youth:

Newer versions of e-cigarettes, such as JUUL, incorporate nicotine salts in a novel product design. These more recently available products have a higher nicotine content, have become immensely popular with users, particularly among youth, and account for a major portion of the e-cigarette market share in the US at this time.^18(p5)

One policy document coded as Policy advocacy (n = 5) described how advocacy campaigns across social media have been used to sway public opinion both for and against tobacco industry practices and regulations:

Tobacco companies are adept at using social media to promote smoking but there has been relatively little use of this means to promulgate anti-smoking messages. An example of some recent social media campaigns have been to use Twitter, Facebook, and change.org to put pressure on musicians not to play at events in Indonesia sponsored by tobacco companies.^19(p76)

Examples of Methods (n = 18) included collecting and analyzing social media posts that demonstrate attitudes and behaviors around tobacco use, as well as social media data that can track marketing messages and strategies. Nearly half of the government policy documents described social media platforms as an academic data source for examining a variety of tobacco-related topics:

Studies have demonstrated that Twitter was a major information-sharing and marketing platform for little cigars and cigarillos ..… The global reach of the internet means that impressionable and vulnerable people may be exposed to indirect product promotion or marketing practices.^20(p.128)

The theme of User experiences (n = 13) appeared when tobacco-related social media research was used to describe how people shared their perspectives and experiences with tobacco products:

A study of a vaping related hashtag on Instagram (#vapelife) suggested that user generated posts establish a social identity among e-cigarette users and that communication within a peer network escalated usage.^21(p.56)

User experiences also captured reports of individuals’ motivations for using tobacco products:

Themes identified … in an analysis of online posts (Reddit) about vaping and mental health included that participants were motivated to vape to self-medicate, quit smoking, for freedom and control, as a hobby, for social connectedness and because of encouragement from caregivers.^22(p.145)

Protobacco (n = 6) was found in government policy documents where tobacco-related social media research was cited to describe positive sentiment and positive portrayals of tobacco use in online media:

Social media may have a role to play in directly addressing social norms towards waterpipe tobacco to combat the positive normative perception that has been observed online. Indeed, from a random sample of 5,000 waterpipe-related tweets in 2014, 87% were deemed to normalise [sic] waterpipe tobacco use by making it seem common, normal to use, and portraying it positively.^20(p.62)

One policy document coded as Intervention (n = 4) described how social media was used to address tobacco prevention and cessation with varying success:

Twitter is often used to build quit-smoking social networks, but one study found the content on these networks is often not consistent with clinical guidelines, and that most of these Twitter accounts are no longer active…YouTube is another widespread medium that could be used to provide education about tobacco products and cessation, but one study found that although there is information on smoking cessation on YouTube, much of that information is not evidence-based.^23(p.56)

Summary Characteristics

The policy documents were published by state (n = 6, 15.8%), federal (n = 20, 52.6%), and international agencies (n = 12, 31.6%). Government offices and agencies that published the most documents citing social media research included the WHO (n = 6, 15.8%), the FDA (n = 6, 15.8%), and the CDC (n = 4, 10.5%), followed by the Office of the Surgeon General (n = 3, 7.9%) and the NASEM (n = 3, 7.9%). The European Commission (EU), U.S. House of Representatives, NIH, and the Public Health Ministries of the UK, Canada, and New Zealand among others, also published policy documents that cited tobacco-related social media research (each agency represented ≤5% of the sample).

The document types included research reports (n = 17, 44.7%), policy recommendations (n = 8, 21.1%), industry guidance (n = 5, 13.2%), legal complaints (n = 5, 13.2%), and practice-based recommendations (n = 3, 7.9%; see Supplementary Table S1). According to Google Scholar, as of February 17, 2023, these documents were cited a total of 3930 times. The three most cited policy documents were the National Academy of Science’s Public Health Consequences of E-cigarettes (2018), Surgeon General’s E-cigarette Use Among Youth and Young Adults (2016), and World Health Organization’s WHO Report on the Global Tobacco Epidemic, 2013: Enforcing Bans on Tobacco Advertising, Promotion and Sponsorship, with 1406, 933, and 750 citations, respectively.

Discussion

This study showed that tobacco-related social media research has been used to inform government policy documents that outline public health concerns, guide industry practices, and make recommendations to stakeholders. Themes related to tobacco industry marketing practices were observed in 76.3% of government policy documents. Furthermore, the present study showed that 68.4% of government policy documents were bringing attention to an issue, such as social media’s potential role in the normalization of tobacco use among youth and young adults. Nearly half of the examined policy documents described social media content as an important data source for public health research. Altogether, this study suggests that continued research on social media platforms will likely inform policy making especially around regulations designed to curb youth exposure to protobacco content.

Tobacco companies have used social media to inexpensively, and at times covertly as with influencers, market tobacco products to millions of adolescents and young adults who are regular social media users.^24,25 The concern over youth exposure to tobacco content on social media was discussed in numerous documents, as youth exposure has been associated with an increase in susceptibility to use tobacco products.¹¹ Social media as a tool in prevention and interventions may be underutilized, as only 10.5% of government policy documents reviewed referred to social media as a tool to deliver a tobacco-related intervention or program. This may be a result of government contracts and grants prioritizing observational research examining tobacco industry marketing, over developing prevention programs and interventions.²⁶ To combat the influence of social media’s protobacco environment, tobacco-related interventions are needed. They should be designed to educate adolescents and young adults about the often covert, deceptive promotion practices of the tobacco industry.²⁷ Such efforts may be beneficial as research has shown that participants exposed to vaping prevention messages, compared to a control group, were more likely to report higher vaping risk perceptions and vaping knowledge.²⁸ Health communication programmers should harness the breadth of research on tobacco-related social media content to design campaigns aimed at countering tobacco industry marketing.

This study found that 47.4% of government policy documents referred to using social media platforms as a data source to examine tobacco-related phenomena. As the tobacco product landscape continues to change, social media platforms will be able to serve as real-time data sources capable of informing regulators of shifts in tobacco industry marketing practices, and user experience with new products. Research that monitors and reports on tobacco-related social media content will continue to provide a lens on the public’s responses to tobacco control policies. Thus, tobacco control researchers should continue to harness digital data sources to better understand, prevent, and intervene in tobacco use behaviors that impact vulnerable populations, such as gender and ethnic minorities, adolescents, and young adults. Further research is needed to overcome the difficulty of interpreting population demographics in social media posts.

Limitations

Documents included in this study were written in English, which may have excluded relevant intergovernmental agency reports in other languages. There are national and international agencies that Overton does not yet search, therefore, an underreporting of legislative documents in this study was possible.²⁹ U.S. states’ official websites were excluded from this search which may have led to underreporting. Furthermore, this study did not examine the impact of government policy documents to inform changes to the law, tobacco industry regulations, or enforcement. It was beyond the scope of this review to assess the key intended stakeholders for such documents, although they would likely include scholars, practitioners, community leaders, policy advocates, and those in tobacco control.

Conclusion

Tobacco-related social media research has been used in government policy documents to discuss tobacco industry marketing and bring attention to youth exposure to tobacco products, like e-cigarettes, whose rise in use has coincided with social media. Future studies are needed to understand how policymakers and advocates use government policy documents to shape tobacco laws or inform public health practices. There is a need for continued research on tobacco marketing across social media and for research on how to best create social media interventions to counter the normalization of protobacco content online. Continued social media surveillance of tobacco products will likely provide timely information to policymakers and public health advocates.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Funding

This study was supported by the California Tobacco Control Branch, Center for Healthy Communities of the California Department of Public Health through contract number 21-10032 Tobacco Industry Monitoring Evaluation (TIME), Grant #U54CA180905 from the National Cancer Institute and the Food and Drug Administration Center for Tobacco Products, and The Regents of the University of California, Research Grants Program Office, Tobacco-Related Diseases Research Program, Grant Number No. T30IR0891. The findings and conclusions in this article are those of the authors and do not necessarily represent the views or opinions of the California Department of Public Health, the NCI, the FDA, or the California Health and Human Services Agency.

Declaration of Interests

Jon-Patrick Allem has received fees for consulting services in court cases pertaining to the content on social media platforms. The authors have no other conflicts of interest to disclose.

Author Contributions

Trista Beard (Data curation [Equal], Formal analysis [Equal], Investigation [Lead], Methodology [Equal], Project administration [Lead], Writing—original draft [Lead]), Scott Donaldson (Data curation [Equal], Formal analysis [Equal], Methodology [Equal], Writing—review and editing [Equal]), Jennifer Unger (Writing—review and editing [Equal]), and Jon-Patrick Allem (Conceptualization [Lead], Funding acquisition [Lead], Methodology [Equal], Supervision [Lead], Writing—review and editing [Equal])

Data Availability

Policy documents included in this review are available upon request. A list of all titles is included in the supplementary table.