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1. Introduction
Health warnings are considered to be an effective method to inform consumers about the risks of smoking, and thereby reduce cigarette consumption [1,2]. However, with the increasing popularity of electronic nicotine delivery systems (ENDS) or e-cigarettes in the United States, the relative and absolute harms of ENDS use has become a subject of heated debate in the public health community [3]. From a continuum of risks perspective, ENDS are likely substantially less harmful than cigarettes [4], potentially offering health benefit to those who completely substitute ENDS for smoking cigarettes [5]. However, the long-term effects of ENDS and their overall public health impact remain unclear [6]. As a result, how health warning messages for ENDS are framed and conveyed to consumers is critically important, and may impact the harm perceptions and use of ENDS and cigarettes.
In May 2016, the U.S. Food and Drug Administration (FDA) issued a deeming rule that expands its regulatory authority to ENDS [6]. By August 2018, the deeming rule will require all ENDS advertisements and packages to carry the warning statement, “WARNING: This product contains nicotine. Nicotine is an addictive chemical”. This statement is required to occupy at least 20% of an advertisement (30% of the principal display panels of the package) and appear in at least 12 point font size. Some ENDS and e-liquid products had already carried voluntary warnings in their advertisements or on product packaging prior to issuance of the final deeming rule [7,8,9,10,11]. However, none of the voluntary warnings meet the font size and placement requirements in the deeming rule, and not all warnings mention nicotine or its addictiveness [7,8,10].
The requirement of an addiction warning for ENDS signifies the important role of harm and addiction beliefs in the use of tobacco products. However, evidence on the effectiveness of ENDS warnings in shaping harm or addiction perceptions and tobacco use is mixed. According to one focus group study, the FDA addiction warning has limited impact on tobacco users who already know nicotine is addictive, but it might inform young non-users [12]. However, some experts in tobacco warning research are concerned about whether this warning resonates with young people [13]. In general, expert opinions and focus group interviews show that modified risk or reduced risk statements...