Online sales and promotion of E-cigarettes in India: A Cross-sectional study

doi:10.21203/rs.3.rs-3127473/v1

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Research Article

Online sales and promotion of E-cigarettes in India: A Cross-sectional study

https://doi.org/10.21203/rs.3.rs-3127473/v1

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Introduction: India is one of the countries to have banned the production, manufacture, import, export, transport, sale, distribution, storage and advertisement of electronic cigarettes (e-cigarettes). With the advent of technology, e-cigarettes are being marketed extensively on the internet despite the ban

Objective: To assess online sales and promotion of e-cigarettes on the internet, and social networking sites (SNS) to identify violations of the current restrictive policies by the e-cigarette industry, SNS platforms and influencers.

Methodology: A survey with youth (18-24 years), along with a desk review was conducted to identify influencers promoting and e-stores selling e-cigarettes in India. Further, a content analysis of the identified influencers and online stores was conducted, along with a analysis of the policies banning online e-cigarette sales and advertisements.

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. A total of 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). In addition, 83 e-stores (49 Indian and 34 international) were identified selling e-cigarettes in India. Findings from content analysis of both influencers and e-stores also highlighted the issue of cross-border marketing. Collected data showed a violation of the restrictive policies by the influencers and e-stores.

Conclusion: To safeguard the youth and move towards Tobacco Endgame; there is a dire need for empowering youth and the community via sensitization programs on the detrimental effects and existing policies related to e-cigarettes in India. Furthermore, strengthening the enforcement of PECA 2019 is the need of the hour to address cross-border advertisements and sales of e-cigarettes, as well as establish strong reporting violation mechanisms.

E-cigarettes

e-cig

influencers

internet

e-stores

social networking sites

India

Vape

policy

The global expansion and evolution of tobacco product landscape led to the emergence of novel products like e-cigarettes.[1] 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.[2] These products are commonly known as ‘vape’ and have gained popularity among adolescents and youth for various reasons.[3] Impulsiveness, desire to experiment with novel products and their exposure to misleading claims increases adolescent risk of initiating this addiction.[4, 5] Additionally, product design, availability in different flavours and perception of being less harmful have enhanced its appeal among youth.[4]

Scientific evidence reveals vaping adversely affects cardiovascular system,[5] impairs respiratory immune cell function and airways in a way similar to cigarette smoking.[6] Disturbingly, their usage among young population has been associated with chronic bronchitis symptoms, and affects 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[7] thus undermining the progress made in tobacco control efforts in each country.

Globally, governments have begun to take action to safeguard youth from e-cigarettes. 32 countries have banned ‘sale of ENDS’ and other 79 countries, have adopted one or more legislative measures to regulate ENDS. While 22 countries including India, have completely banned the advertising, promotion and sponsorship of ENDS.[8] Citing protection of youth and women at reproductive age, the Indian government enforced “Prohibition of Electronic Cigarettes (Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement) (PECA) Act, in 2019.[9, 10] In addition, the Indian government has also enforced “The Guidelines for Prevention of Misleading Advertisement and Endorsements for Misleading Advertisements in 2022 which completely prohibits the advertisement of banned products in the country.[11] These legislative measures are effective as evidenced 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 0.6, 95% CI 0.6, 0.7). [12]

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[13]. E-cigarettes were reportedly sold through retail shops[13] underground markets,[14] online.[15, 16] In today's world, 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 age of 12 and 29 years [17] and during the pandemic, there was an uptick in the usage of the internet especially by youth[18] and the percentage of internet users in India rose by 10.2% during the COVID.[19] Immediately after PECA 2019 was enforced, 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.[20] This study was conceptualised employing scientific methodology to; 1) assess the online promotion and sale of e-cigarettes on social media, and, 2) identify violations of the current restrictive policies by the e-cigarette industry, SNS platforms and influencers.

Study design

A cross-sectional study was conducted using both primary and secondary methods of data collection (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 included a desk review by the study team, to identify e-stores and influencers on the most common SNS platform. Content analysis of identified influencers and online stores through the survey and the desk review was undertaken.

Simultaneously, a desk review also identified restrictive policies in India related to online sale and advertisement of e-cigarettes.

Patient and Public Involvement

Patients or the public WERE NOT involved in the design, or conduct, or reporting, or dissemination plans of our research.

Sample size

The sample size to survey youth was calculated taking into account the Population Census of India 2011.[21] As per the Census report 2011, 19.4% (n = 233,368,000) of the Indian population is between the age group of 15–24 years, margin of error (5%) and level of significance (95% or 1.96) was considered. Based on the above calculation, sample size was calculated to be 384, considering non-response of 10%.

Sampling

A purposive snowball sampling technique was used to recruit youth (18–24 years) from different regions of India i.e., North, West, East, South, Central and North-East as classified under NSSO [22] and Global Adult Tobacco Survey [23]. The initial step included approaching youth through the existing academic institutes [24] 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 collected information on common influencers/people and e-stores selling/promoting e-cigarettes on various SNS, and awareness on PECA 2019. The survey was pre-tested with youth (n = 10) to establish validity. Suggestive changes were incorporated and modified survey was used for the main study. Youth included in pre-testing were not included in main study.

To develop comprehensive list of stores selling e-cigarettes online, a desk review was conducted by researchers(n = 2) independently, based on an internationally approved methodology.[25, 26] 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, 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 influencers search was conducted using hashtags and keywords associated with pro-e-cigarettes products like #vape, #vapelife, #vapenation, #e-cig, #ecigs, #electronic cigarette, and #ENDS as reported in similar studies.[27] Desk review for influencers was only limited to Instagram, as it was the highest reported SNS by the participants via survey.

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 [28, 29]. The detailed list of variables included in the content analysis for e-store and influencers were provided as Table S1

Data Analysis

Collected data from the survey and desk review was cleaned, coded and entered in excel, and analysed via SPSS version 22.[30]. Descriptive statistics including mean, percentages and chi-square test were applied. An analysis was conducted of the legal violations by the e-cigarette industry, social media companies and influencers for online advertisements and sales of e-cigarettes in light of the current prohibitory environment in India.

This section describes the findings from review of existing guidelines and laws regarding online sales and advertisement of e-cigarettes and also discusses findings from the survey and content analysis.

Awareness of Electronic cigarettes and PECA 2019

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. The remaining n = 14 participants, either did not provide consent or were deleted 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 = 0.017). 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% participants.

The majority of participants (93.2%) were unaware of the PECA 2019, which bans e-cigarettes in India.

Influencers Account

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. Out of 189 influencers, only 1.1% were Indian ("@noranbhutia;"@chirag16_unlockedd) 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 counties and for 30.2% of the influencers, information on nationality was not available Among the identified influencers, only 2.1% had a verified account (@danbilzerian, @ignite, @vaustinl, @qorygore).

According to policy analysis (presented in Table 5 in the subsequent section), any person, who takes part in any advertisement that directly or indirectly promotes the use of e-cigarettes, 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, 2019[31] or endorsing e-cigarettes or taking part in surrogate advertisements and indirect advertisements of e-cigarettes.

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 185 influencers was approximately 71 million. Dan Bilzerian (@danbilzerian), from USA," with 32.8 million followers on Instagram had the highest following among our identified influencers (Table 1). The two identified Indian influencers, "@chirag16_unlockedd" and "@noranbhutia" had 13.6K and 11K followers, respectively.

Table 1

Top 10 influencers based on the number of followers
Sl.No	Name of the influencer	Name of the profile of the influencer	Country	Number of followers on the profile*	Date of access
1	Dan Bilzerian	@danbilzerian	USA	32.8 M	21/07/2022
2	Ignite International	@ignite	Maldives	3.7 M	05/07/2022
3	Austin Lawrence	@vaustinl	USA	2.5 M	21/06/2022
4	lady marian	@Glitterina17	Italy	1.1M	23/06/2022
5	QG	@qorygore	n.a	968K	03/07/2022
6	Rip Trippers	@riptrippers	USA	442K	21/06/2022
7	Salvatore Valentino	@salval_naples	Italy	298K	23/06/2022
8	Mattia Garzetta	@mattiagarzetta	Italy	239K	28/06/2022
9	Itjal Febryan	@vapes_aby	Indonesia	235K	21/06/2022
10	Japangold.kz	@japangold.kz	Japan	210K	07/07/2022
*Number of followers are as on date of access

Influencers’ Recent Post

Recent posts (the first post on their account on the date of acesss) 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 were in the form of photos 77.2%, whereas 22.8% were videos.

Brand endorsement and paid partnership

In 81% of posts, the brand name of e-cigarette was visible. Majority of the e-cigarette brands were from China (Voopoo, SMOK, UWell, Geekvapes), USA (Vaporesso) and UK (Efl bar) and none from India.. Moreover, majority (99.5%) of the post did not declare a paid partnership and only, 0.5% of posts had declared paid partnership by tagging a brand (@voopootech_official etc.) on their post. As per the policy analysis, the Guidelines for Prevention of Misleading Advertisements and Endorsements for Misleading Advertisements 2022[11] 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 endorser and the trader/manufacturer/advertiser.

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	*N (%)
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)
*Multiple responses for each post

E- stores selling e-cigarettes: Content Analysis

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 (VAPE SOCIETY SUPPLY™) had a provision for a ‘Photo ID check’ for those above 18 years while purchase or delivery of 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 adverstised 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- 70mg/ml. 53% of e-stores were found selling products with nicotine strength between 0-50mg/ml and only 3.6% of e-stores had products with nicotine strength higher than 50mg/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, 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* (%)
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)

* Multiple responses analysis.

Review of existing guidelines/policies for banning online sales and advertisements of e-cigarettes

The review presented us with two major restrictive policies i.e., PECA 2019 and the Guidelines for prevention of Misleading Advertisements and Endorsements for Misleading Advertisements, 2022 (“2022 Guidelines”) related to e-cigarettes in India.

The PECA 2019 came into force on September 18, 2019, and prohibits the production, manufacture, import, export, transport, sale, distribution, storage and advertisement of e-cigarettes in the interest of public health. The Act applies across media, including electronic media, internet, websites, or social media. The law is notified and monitored by the Ministry of Health and Family Welfare. The most recent Guidelines for Prevention of Misleading Advertisements and Endorsements for Misleading Advertisements, 2022 issued by the Central Consumer Protection Authority [CCPA], Ministry of Consumer Affairs aims to prevent false or misleading advertisements and endorsements and completely prohibits advertisement of banned products. The Guidelines apply to both an advertiser (includes a manufacturer and service provider) as well as an advertising agency, which is defined to mean a person or an establishment providing services in designing and production of advertisements or other related services for a commission or fee.

Table 5

Existing restricted policies banning e-cigarette online sales and advertisements
	Production, Manufacture, Import, Export, Transport, Sale, Distribution, Storage and Advertisement, PECA Act, 2019[9]	Guidelines for Prevention of Misleading Advertisements and Endorsements for Misleading Advertisements, 2022[11]
Prohibition on Advertisements	Prohibits advertisements of e-cigarettes and prohibits persons from taking part in any advertisement that directly or indirectly promotes the use of e-cigarettes. [Section 4(ii)] Prohibition is across media, including electronic media, internet or websites, social media.	Prohibits advertisements of goods which are prohibited from being produced, sold or provided, or which are prohibited from being advertised under any law in force. [Section 9] Prohibits surrogate advertisement or indirect advertisement for goods whose advertising is otherwise prohibited or restricted by law. [Section 6] Specifically regulates endorsers. [section 2(f)]. Restrictions on advertisements also apply to endorsers [section 3(b)].
Prohibition on Sales	Prohibits both direct or indirect selling or distribution of e-cigarettes, including by way of samples, whether free or otherwise. [Section 4(i)] Prohibitions include on agreements for sale, offers for sale, and exposure for sale [Section 3(1)]	N.A.
Penalties	Imprisonment for a term which may extend to three years and with fine which may extend to five lakh rupees [Section 7]	Suspension of endorsers and imposition of fines ranging from ten to fifty lakh rupees [Section 21 of Consumer Protection Act, 2019]

Our study employed a robust scientific methodology to assess strategic use of internet for e-cigarette marketing. We also investigated restrictive policies in India, governing e-cigarette sales and advertisements on internet. The key study findings reveal that influencers and e-stores violated sections 4(i) and 4(ii) of ‘PECA (2019)[9] and Section 6 and 9 of the ‘Guidelines for Prevention of Misleading Advertisements and Endorsements for Misleading Advertisements (2022)’[11] through rampant advertising and sales of e-cigarettes. In addition, there is another Act ‘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 Information Technology Act, 2000).

The study findings emphasise, the lack of awareness among youth about PECA, 2019,[9]. It is crucial to raise awareness among youth, (who are vulnerable to the predatory tactics of the tobacco industry) and community. In India, the effectiveness of school health intervention for preventing and reducing tobacco use is well established[32] and similar interventions must be planned for e-cigarettes. Educational institutes can act as excellent settings[33] for knowledge transactions and building self-efficacy in children, as their social lives revolve around their peers and institute. The existing ongoing national programs like School health programmes under Ayushman Bharat[34], National Tobacco Control Programme[35] and Tobacco Free Educational Institute Guidelines (TOFEI)[36] provide opportunities for sustaining this effort. In addition, 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.[37–39] on smoking and smokeless tobacco. PSA’s have been found effective in many countries[40, 41] and thus a similar national-level public awareness campaign on e-cigarettes and provisions under PECA 2019 could be an effective solution.

A recent report (2022) indicated that despite the ban, 26% of Indian youth have been exposed to e-cigarette marketing through online platforms.[42] 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.[43] It is observed that ‘Facebook’ and ‘Instagram’ have prohibited e-cigarette brands from directly promoting/advertising on their platforms, nevertheless focus has shifted to utilising influencers for promotion.[44] This is worrisome as influencers hold significant potential to channel information across a large number of followers on social media, are extremely persuasive, [45] and also act as role models for youth.[46] Our findings also indicate, 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 ‘cross-border marketing’ of prohibited products which has been reported in the literature.[47]

To effectively enforce the ban on 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.[48] Similarly, Argentina, prohibits cross-country advertisements, especially for social media posts that originate from other countries.[49, 50].

In addition, like many others,[43] 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[51, 52] and these impacts become stronger when endorsed by a celebrity than a non-celebrity.[52] Considering the impact of influencers, recently 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.[53] However, enforcement of these guideline is the need of the hour to protect adolescents and youth in India

Our study also observed both domestic and international e-stores selling and delivering e-cigarettes in India. The availability of various flavours, such as fruit, dessert, candy, menthol, and alcoholic, was also documented in our study. The rationale behind introducing the flavours to tobacco products is to make them more appealing, particularly to youth by reducing their harshness.[54] Both e-stores and influencer marketing strategies focus on hedonic value, cessation, and perceived health benefits, presenting a positive perspective of e-cigarette use. Our study findings also uncover the delivery of e-cigarettes to India by international stores, highlighting the issue of cross borders 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[55], Panama[56] and Portugal [57] 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 for taking appropriate actions.

A few caveats require mention, we did not conceptualize any confounding variables for the current research question, and therefore a regression model was not applied. Also, other social networking sites for example, Facebook, Twitter etc were not explored. In addition, data mining techniques were not utilized in our study but can be explored in future researches. The use of convenience sampling limits the generalisability of results.

The rampant marketing of e-cigarettes threatens 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 establishment of an Inter-Ministerial Task Force, 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, to the extent that such content is not accessible to the Indian audience. A step forward could be to notify more authorized officers, sensitize law enforcers officials to the restrictive environment and the potential violations by the e-cigarette industry, social media sites/platforms, and endorsers/influencers.

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 establishing a mechanism for reporting violations to better protect public health. It is also crucial to empower youth and communities through national-level public awareness campaigns and school health programs that raise awareness on the ill effects /dangers of e-cigarette use and the provisions of PECA 2019.

FUNDING STATEMENT

The study was funded by World Health Organization (WHO) Country Office for India. The funding organisation was also involved in conceptualization and manuscript review.

COMPETING INTEREST: N.A

AUTHOR CONTRIBUTION:

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. Policy analysis was undertaken by KA and content analysis by NT and DB. DB, SB and NT drafted the manuscript and revised as per inputs received from other authors. MA, PS reviewed the manuscript critically for intellectual content. All authors reviewed and approved the final manuscript.

ETHICAL STATEMENT

The study was approved by the PHFI’s Institutional Ethics Committee (TRC-IEC 490/22).

DATA SHARING STATEMENT

Data are available on reasonable request. As per our Institutional data sharing policy, prior approval is required. De-identified data can only be shared after approval of the request.

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No competing interests reported.

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Online sales and promotion of E-cigarettes in India: A Cross-sectional study

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Abstract

BACKGROUND

METHODOLOGY

Study design

Patient and Public Involvement

Sample size

Sampling

Data Collection

Content analysis

Data Analysis

RESULTS

Awareness of Electronic cigarettes and PECA 2019

Influencers Account

Influencers Followers

Influencers’ Recent Post

Brand endorsement and paid partnership

Presence of Warnings

Portrayal of E-cigarettes

E- stores selling e-cigarettes: Content Analysis

Age verification

Product flavours and nicotine strength

Portrayal of electronic cigarettes on e-stores

Review of existing guidelines/policies for banning online sales and advertisements of e-cigarettes

DISCUSSION

CONCLUSION

Declarations

References

Additional Declarations

Supplementary Files

Status:

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