Island breeze, blue lagoon, dew drop—these aren't the names of scented candles on display at your local home goods store. They're flavors of synthetic nicotine used in e-cigarettes, often advertised with neon-electric colors and bright lettering to make them look like boxes of candy or fruit juice. But underneath all the flair, a specific label written clearly in black text on a white background is required by law to be there: a warning that says the product contains nicotine and that nicotine is an addictive substance.

 

Even though health warnings need to be written on physical products sold in stores and included in traditional advertisements, a new research study led by Boston University found that the majority of ads posted on social media by synthetic nicotine brands left the warnings off. The findings have been published in JAMA Network Open.

 

Synthetic nicotine is a substance created in a laboratory that has the same, or very similar, chemical structure to the nicotine derived from tobacco leaves. Despite marketing that labels it as "tobacco-free nicotine," it still has the same addictive properties and additives that can cause lung damage, cancer, and other health issues. Plus, since it's commonly paired with appealing flavors—made from chemicals that are known to be unsafe to inhale—it can be even harder to quit.

 

"When synthetic nicotine started appearing in products, we really wanted to know how it was being received and how it was being promoted," says Traci Hong, a BU College of Communication professor of media studies.

 

When she first started in her career as a health communication researcher, she says, it was a different era: social media was not widely used, cigarette use was declining, and electronic cigarettes and vapes were in their infancy. But when vapes containing synthetic nicotine started getting more and more popular, she turned her attention to social media to find out how the advertising of these products was being regulated—and what could be done to make them less appealing to kids and young adults.

 

In their new paper, Hong and her collaborators found that in over 2,000 Instagram posts from 25 different synthetic nicotine brands, the vast majority did not include warning labels informing users about the health risks.

 

"These are brands that I think have a legitimate responsibility to inform their potential consumers that there are health risks and you need to be aware of them," Hong says. Especially considering that Instagram is one of the most popular social media platforms in the US for young adults.

 

The FDA passed a requirement in 2022 that says health warnings need to take up 20% of the advertising and appear in the upper portion of the advertisement for e-cigarettes that contain synthetic nicotine.

 

Hong, who is a research fellow at BU's Rafik B. Hariri Institute for Computing and Computational Science & Engineering, and her colleagues identified whether an image posted on Instagram included the required health warning and, if it did, whether it took up the right amount of space.

 

The study involved interdisciplinary collaboration across the university, including experts from BU's School of Public Health, Chobanian & Avedisian School of Medicine, and the College of Arts & Sciences.

 

The Instagram posts were analyzed using a custom-built AI algorithm, called Warning Label Multi-Layer Image Identification (WaLi), which uses computer vision to detect if health warnings follow the FDA rules. The team found that only 13% of the analyzed posts complied with FDA health warning requirements.

 

They also discovered that the posts with health warnings received fewer likes and comments than posts without the warnings. According to the paper, the larger the warning label, the less comments the posts received. This means that having health warning labels could reduce how many social media users, especially young adults, are seeing and engaging with this content.

 

"We need federal government policies to combat the appeal of e-cigarette advertising on social media and to prevent kids from using tobacco products," says Jessica Fetterman, a Chobanian & Avedisian School of Medicine assistant professor of medicine and co-author on the study.

 

The FDA recently estimated that the number of middle and high school students using e-cigarettes in 2024 is about 1.63 million, down from 2.13 million in 2023, with the vast majority using flavored nicotine. Enforcing and requiring health warning labels on social media content is one way to make products less visible and appealing, Fetterman says.

 

"Our study indicates that e-cigarette brands are creating Instagram posts advertising their products with seemingly no enforcement by the social media platform or government," Fetterman says. Instagram lists tobacco products, electronic cigarettes, "and any other products that simulate smoking" on their list of prohibited branded content. But, Fetterman says, synthetic nicotine products are flouting that rule.

 

"All our work is really trying to find evidence-based research to help people make informed decisions about their health," Hong says. With synthetic nicotine and e-cigarette companies continuing to use flavors as a way to appeal to youth, she says, her team plans to monitor social media posts with WaLi to ensure brands are using the correct language to dissuade people from getting hooked.