Health Messaging Strategies for Vaping Prevention and Cessation Among Youth and Young Adults: A Systematic Review

Figures & data

Table 1. The McGuire’s Communication/Persuasion Model outputs.

Variable		Description
Inputs	Source	The individual, group, or organization that the audience perceives as the communication originator
	Message	What is being communicated and how it is being conveyed
	Channel	The medium or platform through which the message is being transmitted
	Audience	The intended target group, including their demographics, attitudes, and current behaviors, among other relevant factors
	Destination	The desired outcome of the communication, which may involve changes in the audience’s attitudes, beliefs, or behaviors in a specific domain
Outputs	Exposure	Exposure to the message
	Attention	Paying attention to the message
	Liking or interest	Liking and being interested in the message
	Comprehending	Understanding the message
	Cognitive elaboration	Generating related cognitions to the message
	Skills acquisition	Gaining the appropriate skills to act on the message
	Attitude change	Agreeing with the communication’s position
	Memorization	Saving the message to memory
	Recall/recognition	Retrieval of the message from memory when needed
	Decision-making	Acting on the message
	Behavioral change	Performing the action
	Maintenance	Integration of the action into long-term behavior
	Advising others to behave likewise	Proselytizing other people to behave likewise

Table 2. Three classes of theories for health messaging, adapted from Cappella (2006).

Theory class	Definitions	Examples
Behavior change theory	Theories describing rational, emotional, social, and personal predictors of healthy and risky behavior	The theory of planned behavior (Ajzen, 1991); Transtheoretical Model (Prochaska & Velicer, 1997)
Message effect theory	Theories predicting the format and content of messages that produce effects on cognitive, attitudinal, and emotional outcomes.	Emotional appeals (Nabi, 2007); Message frames (Rothman & Salovey, 1997)
Human information processing theories	Theories pertinent to the process of behavior changes	Limited capacity model of motivated mediated message processing (Lang, 2000); Elaboration likelihood model (Petty & Cacioppo, 1986)

Figure 1. PRISMA flow diagram showing the study screening process.

Read the detailed description of this figure

This PRISMA flow diagram shows the study screening process of the systematic literature review. The diagram has four main sections: Identification, Screening, Eligibility, and Included. Each section shows the number of studies or records that were identified, screened, assessed, and included at each stage of the review process, as well as the reasons for excluding some studies or records. The diagram shows that the researchers searched 10 databases and registers and identified 6045 studies or records. After removing 3790 duplicates or irrelevant records, they screened 2255 studies or records by reading their titles and abstracts. They excluded 2109 studies or records for unspecified reasons, leaving 146 studies or records for full-text retrieval and eligibility assessment. None of the studies or records were not retrieved, but 121 were excluded for various reasons, such as qualitative research, study protocol without data, non-empirical research, studies on non-youth/young adult participants, or studies on health warning labels on e-cigarettes ads or promotions. The final number of studies or records included in the review and analysis was 25.

Table 3. Study characteristics and theoretical framework.

	Study characteristics				Theory	Destination
	Research method	Participant age range; Country of study	Sample size	Study design	Employed theory	Focus on vaping cessation
Boynton et al., (2022)	Content analysis of existing anti-vaping ads Survey	13 to 17; US	1,501	Cross-sectional	n/a	No
Cai & Zhao, (2021)	2 (frame) × 2 (uncertainty tolerance) factorial experimental design	13 to 17; US	536	Cross-sectional	Message effect theory Prospect theory Behavior change theory Uncertainty tolerance	No
Calabro et al., (2019)	Two-group (gain vs. loss frame) randomized pretest and posttest experimental design	18 to 24; US	95	Longitudinal: participants received 4 texts weekly for 30 days	Message effect theory Prospect theory	No
Cartujano-Barrera et al., (2022)	Four-group (four themes) randomized pretest and posttest trial	13 to 17; US Black and Latino adolescents	362	Cross-sectional	Behavior change theory Biobehavioral model of nicotine addiction	No
Clayton et al., (2020)	2 (condition: dogmatic versus suggestive language) × 3 (audio probe) × 4 (message repetition) factorial experimental design	18 to 28; US	155	Cross-sectional	Human information processing theories Psychological reactance theory Limited capacity model of motivated mediated message processing (LC4MP)	No
Graham et al., (2020)	Two-group (This is Quitting intervention vs. control) randomized clinical pretest and posttest trial	18 to 24; US	2,588	Longitudinal: participants received monthly assessments for 7 months	Human information processing theories Social cognitive theory	Yes
Jun et al., (2021)	2 (gain vs. loss frame) ×2 (self vs. group affirmation) factorial experimental design	College students; US	219	Cross-sectional	Message effect theory Prospect theory Behavior change theory Self-affirmation theory	No
Kong et al., (2016)	Survey	Middle/high school or university students; US	5,405	Cross-sectional	Message effect theory Prospect theory	No
Lazard, (2021)	3 (message formats) × 6 (theme) factorial experimental design	15 to 18; US	928	Cross-sectional	Message effect theory “Mix of attributes” theory-based design	No
Lee & Stevens, (2022)	Two-group (expert vs. peer message source) randomized experiment	18 to 30; US	302	Cross-sectional	Message effect theory Source credibility theory	No
Lee et al., (2022)	Three-group (3 themes) randomized experiment	18 to 30; US Sexual minority individuals	457	Cross-sectional	Behavior change theory Social identity theory	No
S. Liu & Yang, (2020a)	2 (narrative vs nonnarrative) × 2 (gain vs loss frame) factorial design experiment	College students; US	441	Cross-sectional	Message effect theory Prospect theory Message narrative	No
S. Liu & Yang, (2020b)	Two-group (narrative vs. non-narrative) randomized experiment	College students; US	439	Cross-sectional	Message effect theory Message narrative Human information processing theories Theory of psychological distance	No
J. Liu et al., (2023)	Survey	18 to 30; US	459	Cross-sectional	n/a	No
Noar et al., (2019)	Pretest-posttest within subject experiment	14 to 18; US	69	Longitudinal: participants received e-cigarette harms message per day for six days	n/a	No
(Noar et al., (2022)	Three-group (2 themes + 1 control) randomized clinical trial	13 to 17; US	1,514	Longitudinal: participants saw 3 randomly ordered 30-second video advertisements online at each of 3 weekly study visits	Behavior change theory The theory of reasoned action	No
Patterson et al., (2022)	3 (theme) by 3 (image format) factorial design experiment with a control condition	18 to 30; US Sexual minority women and nonbinary people assigned female at birth	501	Cross-sectional	n/a	No
Rath et al., (2021)	Survey	15 to 24; US	1,564	Cross-sectional	Message effect theory The Hornik and Woolf health communication framework	No
Rohde et al., (2022)	Five-group (themes) randomized experiment	13 to 17; US	623	Cross-sectional	n/a	No
Sanders-Jackson et al., (2019)	2 (presence vs. absence of vapor) x 4 (message repetition) between subject experiment	21 to 30; US	71	Cross-sectional	Human information processing theories Associative Learning Theory LC4MP	No
Stevens et al., (2021)	Participants randomly view and rate six of the 32 images	18 to 24; US	200	Cross-sectional	n/a	No
Tan et al., (2018)	Four-group (themes) randomized experiment	21 to 30; US Smokers and dual users	293	Cross-sectional	n/a	No
Villanti et al., (2021)	2 (content) × 3 (theme) factorial experimental design	18 to 24; US	200; 769;	Cross-sectional	n/a	No
Xu et al., (2023)	Three-group randomized experiment	College students; US	137	Longitudinal: one time exposure, collect data pretest, immediate after the test, and 1 week later	Human information processing theories Theory of psychological distance	No
Zhao et al., (2023)	2 (framing) × 2 (format) factorial design experiment	13 to 17; US	1,084	Cross-sectional	Message effect theory Prospect theory Message narrative	No

Table 4. Main and interaction effects of communication inputs.

	Studied communication inputs	Measured communication outputs	Main effects of communication inputs	Stratified and/or Interaction effects of communication inputs
Boynton et al., (2022)	Message elements: Themes Imagery Other features Audience vaping status: Current users Susceptible non-users Non-susceptible non-users	Interest or liking: vaping appeal PME	Message elements: Interest or liking (vaping appeal): Flavor theme and imagery associated with food increased vaping appeal across all groups. PME: Themes Associated with Increased PME: nicotine addiction, chemicals, negative health effects, health symptoms, comparison to cigarettes, non-harmless water vapor, death, unknown health effects, gateway effects, warning symbols, graphic images, combustible cigarettes Themes Associated with decreased PME: industry targeting, flavors, environmental impact, faces (both adult and teen), food No effect: vaping device imagery	Stratified by audience vaping status: Interest or liking (vaping appeal) Imagery associated with food had no impact for current users and a modest positive effect for non-users. PME Effective among non-users but not users: the word “addiction,” themes on brain effects, and non-harmless water vapor Effective among users but not non-users: theme on lung effects Effective among users and susceptible but not non-susceptible: themes on death and nicotine chemical symbol
Cai & Zhao, (2021)	Message framing: Gain frame Loss frame Audience uncertainty tolerance: High tolerance Low tolerance	Positive affect Negative affect Attitudes: attitudes and risk beliefs of vaping Decision-making: intention to vape PME	Framing: Loss frame was overall better received and more effective compared to gain frame on: Negative affect Attitudes: risk beliefs of vaping Decision-making PME Uncertainty tolerance: Lower in uncertainty tolerance produced more desired outcomes on: PME (single and multi-items), Negative affect Positive affect Attitudes: risk beliefs of vaping	Framing × uncertainty tolerance: Gain framing is more effective for those with low uncertainty tolerance, while loss framing is more effective for those with high uncertainty tolerance on PME (single and multi-items) Attitudes (negative beliefs and attitudes) Decision-making (intention to vape)
Calabro et al., (2019)	Message framing: Gain frame Loss frame	Attitudes: risk beliefs of vaping Memorization: knowledge about e-cig harm	Framing: Gain frame produced more desired outcomes on: Attitudes (risk beliefs of vaping)	n/a
Cartujano-Barrera et al., (2022)	Themes: Health rewards; Financial rewards; Autonomy; Social norms	Liking and interest: satisfaction and willing to share with friends Decision-making: susceptibility to future vaping	Themes: None of the themes reduced participants’ susceptibility to vaping in the future	n/a
Clayton et al., (2020)	Language style: Dogmatic Suggestive	Cognitive elaboration: threat to freedom; reactance; counterarguing; encoding Negative affect: anger Decision-making: intention to vape	Language style: Suggestive messages led to more desired outcomes than dogmatic messages on Cognitive elaboration: perceived freedom threats; counterarguments; response times; encoding of content Negative affect: anger, Decision-making: intentions to vape
Graham et al., (2020)	Message intervention: This is quitting Control Audience characteristics: Demographics Nicotine dependence	Behavioral change: self-reported 30-day point prevalence abstinence at 7 months	Message intervention: Behavioral change: participants who received the intervention were one-third more likely to quit vaping at the 7-month primary end point compared with control participants.	Intervention × audience characteristics: The study did not find any significant interaction effects between the intervention and any audience characteristics, including nicotine dependence
Jun et al., (2021)	Message framing: Gain frame Loss frame Audience affirmation: Self-affirmation Group-affirmation Vaping status: Vapers Non-vapers	Attitudes: Vape-free policy support	Framing: No significant framing effects Audience affirmation: Attitudes: self-affirmation is associated with a higher level of vape-free policy support than group-affirmation Audience vaping status: Attitudes: Non-vapers reported higher levels of policy support than vapers	Framing × audience affirmation No interaction effects Framing × audience affirmation × vaping status Attitudes: for vapers, the level of policy support was the highest when they were self-affirmed and exposed to a gain-framed message. For non-vapers, the level of policy support was the highest when they were self-affirmed and exposed to a loss-framed message
Kong et al., (2016)	Message framing: Gain frame Loss frame Themes Financial cost Health risks Addiction Social labeling as a smoker Audience characteristics Audience school level Audience sex Audience vaping status Lifetime users Never users	Liking or interest: preference of the message	Framing: Liking or interest: 1) Loss frame was preferred over gain frame for themes related to health risks, addiction potential, and social labeling as a smoker; 2) Gain frame was preferred over loss frame for the theme related to financial cost Audience characteristics: Liking or interest: 1) females preferred loss-framed messages for all themes relative to males; 2) lifetime e-cigarette users preferred loss-framed health risks and social labeling messages relative to never users; 3) high school students preferred gain-framed social labeling messages relative to college students	Among never e-cigarette users: Liking or interest: 1) females prefer loss-framed messages across all four message themes than males; 2) preference for gain- vs. loss-framed messages did not differ by cigarette susceptibility or e-cigarette susceptibility status
Lazard, (2021)	Message format: Visual based, Quiz Text only Themes: Lung damage Contains chemical Mood effect Nicotine effect Can explode Vape designs Audience vaping status Current users Ever users Susceptible to future use	PME Positive affect Negative affect Cognitive elaboration Memorization: knowledge about e-cig harms Attitudes: risk beliefs of e-cigs Advising others to behave likewise: sharing with others	Message format: No main effects Themes: Lung damages produced more desired outcomes on: PME: compared to mood change; nicotine effects; vape design Cognitive elaboration: nicotine effects; can explode; vape design	Message format/theme × vaping status No interaction effects: e-cigarette use status did not moderate the effects of message theme or format on message reactions.
Lee & Stevens, (2022)	Message sources Expert Peer Audience vaping status Current users Former users Never users	Liking or interests: credibility Attitudes: risk perceptions of e-cigs Decision-making: intention to use e-cigs	Message source: The expert message produced more desired outcomes than peer message on: Liking or interests: credibility	Message source × vaping status No interaction effects
Lee et al., (2022)	Themes E-cig health harms Pride Wellness Audience LBQ identity	PME	Audience SGM identity: PME: affirmation of a few gender minority (SGM) identities was significantly positively associated with PME	Message theme × SGM identity PME: Positive effects of identity affirmation on PME were more pronounced when participants viewed pride-themed messages compared to wellness or harms messages
S. Liu & Yang, (2020a)	Language style Narrative Non-narrative Message framing Gain frame Loss frame	Attitudes: risk perception of e-cigs Decision-making: intention to use e-cigs	n/a	Narrative style × message framing Decision-making: 1) Gain-framed narrative, compared to non-narrative led to lower intention to use e-cigs 2) Loss-framed narrative decreased intention to vape through stronger sadness and higher risk perception.
S. Liu & Yang, (2020b)	Narrative language style Narrative Non-narrative Audience vaping status Ever users Never users	Positive affect Negative affect Attitudes: risk perception of e-cigs; perceived susceptibility; perceived severity Decision-making: intention to use e-cigs	Narrative language style: Narrative messages produced more desired outcomes than non-narrative messages on: Transportation → affect → attitudes (serial mediation)	Narrative style × vaping status Attitudes: Participants who have not used e-cigs before report more negative attitude after reading the narrative message than those who have used e-cigs
J. Liu et al., (2023)	Audience vaping status: Never use of e-cigarettes Past 30-day e-cigarette use Ever use of e-cigarettes Audience social media use	Liking and interest: engage with the posts	Audience characteristics: Liking and interest: 1) E-cig use status (ever vs. current) did not affect participants’ intention to engage (e.g., like, comment on) with anti-vaping social media posts; 2) Total number of social media sites used was associated with intentions to “like” the posts and the overall engagement score; 3) Daily internet use was associated with intentions to “comment on” and “like” the posts.	n/a
Noar et al., (2019)	Themes: Chemical Brain Nicotine	PME Memorization: e-cig knowledge Recall/recognition: message recognition Cognitive elaboration Attitudes: perceived risk Decision-making: vaping susceptibility; wiliness to use e-cig Advising others to behave likewise: sharing with others	Themes: Chemical and brain messages produced more desired outcomes than nicotine messages on: PME Fear 2) Nicotine messages produced higher values than chemical messages on: Recall/recognition	n/a
Noar et al., (2022)	Themes: Health harm Addiction Control	Primary Decision-making: vaping susceptibility Secondary Negative affect Cognitive elaboration Attitudes: vaping health harm risk perceptions; vaping addiction risk perceptions; vaping attitudes Advising others to behave likewise: social interactions	Themes: The Real Cost groups did not differ from one another on susceptibility and secondary outcomes to vaping and all other message reactions at visit 4.	n/a
Patterson et al., (2022)	Themes: Harms Wellness Pride Image format: Individual Couple Cartoon formats Audience vaping status Current users Former users Never users Audience sexual identity	PME Attitudes: changes in feelings toward e-cigs; perceived threat Decision-making: discouragement from vaping	Themes: Harm messages produced more desired outcomes than wellness and pride themes on: Decision-making: intention to vape Image format: Female-presenting couples scored higher than cartoon images on: PME	Stratified effect across vaping status: Theme Decision-making: Current e-cig users reported greater intentions to abstain from vaping when they viewed harms-themed messages compared to current e-cig users who were in the control condition, the pride condition, and the wellness condition. Image format Decision-making: Current e-cig users who viewed an image of an individual woman reported higher readiness to avoid vaping and higher intentions to abstain than those in the control condition, the cartoon condition, and the couple condition. Sexual identity × message theme/image format Sexual identity did not modify the effect of message theme and image format on any outcomes
Rath et al., (2021)	Theme: Social acceptability of vaping Anti-vape industry sentiment Independence from vaping Non-vaping identity Perceived risk of harm Audience vaping status: Current users Ever users Susceptible never-users Non-susceptible never-users	Attitudes: anti-vape attitudes and beliefs	n/a	Message theme × vape use status Attitudes: target message theme scales varied based on vape use status: 1) non-susceptible never-users had highest mean scale scores followed by susceptible never-users, ever users, and current users followed in decreasing order
Rohde et al., (2022)	Themes Chemical harms Lung harms COVID-19 harms nicotine addiction control (messages about vape litter) Audience demographics	Primary PME Secondary Negative affect Attention Advising others to behave likewise: social interaction	Themes: PME: Adolescents rated chemical, lung, and COVID-19 harms higher on PME than nicotine addiction and control while nicotine addiction was rated higher than control Negative affect: Chemical, lung, and COVID-19 harms elicited greater negative affect than nicotine addiction and control	Message theme × vape use status No interaction effects on PME: The warning message theme had no interaction with age, gender, race, Hispanic ethnicity, household income, sexual attraction, or vaping status
Sanders-Jackson et al., (2019)	Message feature: Presence of vapor Absence of vapor	Cognitive elaboration: Psychophysiological measures Positive affect Memorization: knowledge of vaping risks Decision-making: urge to vape	Vapor: The presence of vapor activates the approach/appetitive motivational system, leading to greater Positive affect: Cognitive elaboration Memorization Decision-making: urge to vape
Stevens et al., (2021)	Message features People Vapor Device Color Similarity to warning label image Audience vaping status Current users Non-users	PME Liking or interest	Message feature: Liking or interests: 1) Images with vapor, devices, or e-liquid, were not well-liked than images without those features; 2) warning label images were not well-liked than those without a warning PME: Images with vapor, devices, or e-liquid, were perceived as more effective than without the features; 2) warning label images were perceived as more effective than those without a warning	Stratified effect across vaping status: PME: 1) Presence of vapor was seen as more effective for non-users and users; 2) Presence of e-liquids and device was more effective and likable for non-users; 3) The presence of color was seen as less effective for non-users only
Tan et al., (2018)	Themes: Anti-vaping PSAs with vapor Anti-vaping PSAs without vapor Physical activity PSAs Antismoking PSAs with smoking cues Audience vaping status; Smokers Dual users of cigarettes and e-cigarettes	Decision-making: changes in vaping urge; intention to vape in the next hour; Intention to purchase vapes; Changes in smoking urge; Intention to smoke in the next hour; Intention to purchase cigarettes	n/a	Stratified effect across tobacco use status: Smokers Only: Decision-making: 1) Exposure to anti-vaping PSAs with vapor (vs. control) linked to lower intention to vape and purchase e-cigs, lower intention to smoke and purchase cigarettes; 2) Exposure to anti-vaping PSAs with vapor (vs. PSAs without vapor and vs. anti-smoking PSAs with smoking cues) linked to lower intention to vape; 3) Exposure to anti-vaping PSAs without vapor (vs. control) associated with lower vaping urge and lower intention to purchase ENDS Dual Users: Decision-making: Exposure to anti-vaping PSAs without vapor (vs. anti-smoking PSAs) associated with lower intention to purchase ENDS.
Villanti et al., (2021)	Message content: Addiction Harm Themes: Alone Flavor Social	PME Liking and interest: likability of the message	Main effect of content themes: PME: 1) Harm content messages produced higher PME than addiction content messages; 2) Adding flavor and social message themes to harm content messages decreased the PME Liking and interest: Adding flavor theme to harm and addiction content were correlated with higher likability scores	n/a
Xu et al., (2023)	Message content: VR-self VR-other Print	Liking and interest: vaping interest Attitudes: perceived harm of secondhand aerosol (SHA) Decision-making: prevention intentions Advising others to behave likewise: persuade others to quit vaping; persuade others to not vape nearby	Main effect of VR game: VR massages produced more desired outcomes than print messages on: Liking and interest: 1) VR-other generated less vaping interest immediately; 2) Both VR-Self and VR-Other generated less vaping interest after 1 week. Attitudes: VR-Other generated a higher level of perceived harm of secondhand harm than the print advertisement after 1 week.	n/a
Zhao et al., (2023)	Message framing: Gain frame Loss frame Message format: Individual texts Simulated exchange	Negative affect Positive affect PME Liking and interest: message liking Attitudes: beliefs of e-cig harms; attitudes Decision-making: intention to quit	Main effect of framing: Compared to gain frame, the loss frame generated stronger Negative affect Main effect of message format: Simulated text exchanges produced more desired outcomes than individual text messages on: Liking and interest: better liked PME Positive affect Attitudes: beliefs about e-cigarettes	Message frame × message format In simulated exchange conditions, the gain frame outperformed the loss frame for: Liking and interest Positive affect Attitudes Decision-making: intention to use The reverse trend was observed in individual text conditions.

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