Vaping in the News: The Influence of News Exposure on Perceived e-CigaretteUse NormsHue Trong Duong and Jiaying Liu

University of Georgia

ABSTRACTBackground: Research has documented the impact of descriptive norms on tobacco use, but fewstudies have investigated how media exposure shapes e-cigarette use norms.Purpose: The purpose of this study was to examine how exposure to e-cigarette-related newsarticles shapes individuals’ descriptive norm perceptions about real-world e-cigarette use.Method: The study implemented an experiment with a 2 normative direction (high vs lowprevalence) × 2 exposure dosage (single vs double dose) between-subjects factorial design(N = 298). Analysis of variance and thematic analysis were conducted.Results: Normative direction and exposure dosage of prevalence information contained in thenews articles interacted to influence perceived descriptive norms. Increasing the dosage ofprevalence information enhanced descriptive norm perceptions in low-prevalence conditionsonly. Participants relied on institutional signals and behavioral cues to infer descriptive normswhen prevalence information was absent in the news.Discussion: The study investigates the underlying mechanism of how news articles may influencenormative perceptions.Translation to Health Educational Practice: Given that news media may inadvertently formsocial norms that are conducive to e-cigarette use behavior, Health Educators should pay atten-tion to descriptive norms emanated from the news media environment. They should also considernorm debiasing strategies and the integration of dosage of low-prevalence information into socialnorm messages.

ARTICLE HISTORYReceived 29 August 2018Accepted 9 October 2018

Background

Electronic cigarettes (e-cigarettes) are battery-powereddevices that produce an aerosol by heating a liquid thatusually contains nicotine and other chemicals. The behaviorof e-cigarette use is referred to as vaping because e-cigaretteusers (or “vapers”) inhale and exhale aerosol or vaporinstead of cigarette smoke. E-cigarettes are now the mostcommonly used tobacco product by youth in the UnitedStates.1 Aggressive marketing strategies by tobacco compa-nies on the Internet and socialmedia promote e-cigarettes asa “harmless” and “cool” product replacement for conven-tional cigarettes, which is appealing to the youngerpopulation.2–4 Because of the inconclusive scientific evi-dence related to the impact of e-cigarette use on healthrisks,5 e-cigarette use has seen a heated debate among thescientific community and policymakers about how to reg-ulate this new product.6 The controversy has triggeredmuch media attention in recent years.7 The sheer numberof media focusing on the e-cigarette debate may

inadvertently have a significant effect on media usersthrough “social exposure”—a concept that describes thevarious ways in which people come in contact witha particular behavior that shapes their norm perceptions.8

Despite the assumption that mass media play a role inproducing normative perceptions, research has so farmostlyexamined how interpersonal influences affect norm percep-tions. Social norm researchers noted that other significantsources for the development of norms, including the massmedia environment, have not sufficiently been researched,which undermines the understanding of the link between anindividual’s environment and the formation of social normsabout a health behavior.8

The present research investigates how exposure to newsarticles about the controversy surrounding e-cigarette usemay shape individuals’ perceived prevalence of the behavior,namely, perceived descriptive norms.9 In particular, weexamine this question among a sample of college students,who are increasingly using e-cigarettes.10 Scholars have

CONTACT Hue Trong Duong hue.duong25@uga.edu Department of Communication Studies, University of Georgia, 513 Caldwell Hall, Athens, GA 30602.Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ujhe.

AMERICAN JOURNAL OF HEALTH EDUCATION2019, VOL. 50, NO. 1, 25–39https://doi.org/10.1080/19325037.2018.1548315

© 2018 SHAPE America

called for considering college students as a distinct prioritypopulation due to their developmental context, needs, andcommunity.11,12 According to the theory of normative socialbehavior (TNSB), perceived descriptive norms influencebehavior.13 Accumulating studies have empirically docu-mented the powerful impact of descriptive norms acrossbehavioral domains and cultural contexts.14–17 Many socialnorms campaigns in the United States aim to promotepositive behavior changes through readjusting individuals’biased descriptive norms related to the target behavior.18

Public health campaign messages utilizing normativeappeals often craft messages by incorporating normativeinformation that indicates either a low prevalence of anundesired behavior or the high prevalence of a desired beha-vior to encourage behavior changes through conformity toperceived norms in society.19

News articles often contain behavior prevalence state-ments with the goal of informing the public. In addition,because news is the product of a social institution, it maycarry potential heuristic cues to normative perceptions.20

However, compared to sophisticatedly crafted behaviorchange campaign messages with a clear intent to persuade,normative information in a news article is only part of itsnews content. Though effects of normative messages havebeen studied extensively in the context of persuasivecommunication,21,22 no study has examined how norma-tive statements embedded in news articles, which are con-sidered routine information sources, may influenceindividuals’ normative perceptions. When examiningthe underlying mechanisms of normative formation, scho-lars focused heavily on the influence of movies and televi-sion rather than that of news.8Moreover, there is also a lackof knowledge on the cues or sources that people rely on toinfer descriptive norms in the general population in theabsence of explicit prevalence information in news content.To address this gap, the present study aims to examine (a)whether news articles containing behavior prevalenceinformation would affect readers’ overall descriptive normperceptions and (b) how perceived descriptive norms canbe inferred from news articles that do not explicitly containprevalence information. Because the link between per-ceived descriptive norms and behavioral intentions hasbeen consistently established in the literature, the focus ofthe present study is on normative perception formation tocontribute to norm-building theory. Despite the extantresearch on social norms theory, the sources of norm for-mation are insufficiently studied.8

Theory of normative social behavior

Social norms are broadly defined as social codes toguide a course of action that would be perceived asmost beneficial, or what ought to be done, and typical

for individuals, or the prevalence of the behavior.9

Theorists distinguish these two types of norms asinjunctive and descriptive norms. Injunctive anddescriptive norms share similarities in that they areinformational in nature and that they exist at bothsocial and individual levels. At the individual level,social norms are perceived by individuals based onvarious social and behavioral cues. The conceptual dis-tinction between the two types of norms is that injunc-tive norms involve social sanction, whereas descriptivenorms do not.13

The TNSB theorizes the association between descrip-tive norms and behaviors with a focus on factors thatinfluence this association.23 Cognitive mechanisms,such as outcome expectations, group identity, impres-sion management, self-efficacy, psychological involve-ment, and injunctive norms, have been studied asmoderators in TNSB research. Researchers found theinteraction effects between these variables with descrip-tive norms to influence various healthbehaviors.16,17,24,25 When controlling for these modera-tors, researchers found that the main effects of descrip-tive norms remain substantial for food consumption,drinking alcohol, and recycling.16 When the two typesof norms are in conflict, researchers found that descrip-tive norms can outweigh injunctive norms to assertmore influence on some risk behaviors.26 Perceiveddescriptive norms were also found to positively corre-late with the use of e-cigarettes among the collegestudent population.12 Clearly, the link between descrip-tive norms and behavior has been well established,which contributes to resolving the mixed results ofsocial marketing campaigns that utilize the socialnorms approach on American campuses.27

Critiques of TNSB research have been raised, includingthe methodological approach that is overly dependent oncross-sectional surveys and the lack of attention to norm-building processes.16,17,28 Simultaneously, researchers havesuggested extending the theory by examining constructsaccounting for how or where descriptive norms developand change.28 This extension adds depth to understandingnormative influence, particularly regarding the relationshipbetween communication variables and norm formation.8

The body of research on the social norms approach hasindicated that descriptive norms are perceived upon thereception of information from interpersonal communica-tion andmassmedia that convey unhealthy behaviors, suchas drinking, smoking, and substance use.29 However, thesources of social norms, particularly those related to themediated environment, are insufficiently documented.8 Inthis study, therefore, we focused our investigation on thenorm formation process, rather than on the well-documented link between norms and behavior.

26 H. T. DUONG AND J. LIU

The e-cigarette debate and media coverage

e-Cigarette use is currently one of the most divisive topicsamong the public health community.5 Proponents ofe-cigarettes extol the product as an alternative technologywith “harm reduction” in comparison to cigarettes.7

Specifically, promoters of e-cigarettes posit that e-cigarettesaid in smoking cessation and are less harmful. These argu-ments are broadly advertised in e-cigarette marketing.30

Opponents, however, are skeptical of the long-term healthconsequences of vaping and are concerned that e-cigarettesmay encourage smoking initiation by increasing nonsmo-kers’ chance of getting addicted to nicotine, particularlyamong young adults.31 Recent research found that vapinge-cigarettes may be positively associated with smoking,32,33

and the depiction of vaping in commercials increases thetemptation to smoke.34 Exposure to vicarious vaping beha-vior was found to be associated with potential renormaliza-tion of smoking among ever and potential smokers,10 whichin turn leads to smoking-related chronic diseases.Moreover,recent research suggested that vaping may directly disablekey immune cells in the lung and boost inflammation.35

The debate about e-cigarettes, therefore, has spurredjournalistic coverage at both the national and globallevels. Inconsistent legal frameworks regarding e-cigaretteuse in different states in the United States, as well asamong different countries, contributes to the salience ofthe e-cigarette debate in the news.36,37 Content analysis inUK and Scottish newspapers indicated a significantannual rise in news reporting about e-cigarettes.7,38 Thefindings revealed the divisive nature of the topic, largelydue to inconsistent scientific evidence. Research in SouthKorea also showed a similar trend in e-cigarette newscoverage.6 In the United States, researchers found thatthe majority of news articles about e-cigarettes were pub-lished in recent years, with 85% of the articles reportinge-cigarettes as neither favorable nor unfavorable.39

The inundation of e-cigarette-related news in media hasbeen found to predict news consumers’ attitudes and beha-viors. For example, a recent study showed that informationseeking in the media environment leads to a greater like-lihood of e-cigarette experimentation among youth.40 Theresultswere attributed to theprevailingpro-e-cigarette infor-mation in the media environment and the discussion aboutcomparative health risks between smoking and vaping.However, limited research has examined the influence ofe-cigarette use prevalence information, which is frequentlyreported or depicted in news articles, on readers’ beliefs andperceptions. In addition, given the growing evidence of theoverestimation of tobacco product–related descriptivenorms and the association between perceived descriptivenorms and e-cigarette use behavior,3,12,41 it is important toexamine how the perceived descriptive norms surrounding

e-cigarette use were formed through media consumption.Considering that younger populations are at a developmentstage where they are particularly sensitive to normative cuesinmassmedia42 and that the college-aged populationhas themost dramatic increase in risky behaviors and substanceuse,11,43 the present study aims to examine how collegestudents’ descriptive norm perceptions are formed asa result of exposure to news articles reporting e-cigaretteissues.

Purpose

The purpose of this study is to examine whether andhow exposure to e-cigarette-related news articles shapesindividuals’ descriptive norm perceptions about real-world e-cigarette use. In the section that follows, wediscuss specific hypotheses and research questions.

Influence of media exposure on prevalenceperceptions

The effect of normative messages in persuasion context onnormative perceptions have been well documented21,22,44

but is insufficiently examined in news media. Social normcampaign messages often convey behavioral prevalenceinformation with explicit summary statements, such as“the majority of college students do not drink whenpartying.”19,45 However, it is not yet known whether similarsummary information embedded in news articles wouldproduce a similar effect. Presumably, readers may processsuch normative information quite differently compared toan intentionally persuasive message in health campaigns.News articles, particularly those reporting scientifically con-tested health topics, are basically not produced for thepurpose of persuasion but instead to inform readers.Journalists tend to report scientifically contested issues inan impartial manner and focus more on surroundingdebates, as reviewed above, than making the prevalenceinformation salient to users. Moreover, information proces-sing theory suggests that media users may pay attention toonly selected subsets of information that are availablein media content.46,47 Because normative informationincluded in the news is not saliently depicted as it isin social norm campaigns, it has to compete with variousother types of information content conveyed by the news.For example, e-cigarette news stories have focused substan-tially on the progress of scientific findings and reactions ofrelevant organizations. Journalists also pay attention to leg-islative frameworks, tobacco companies’ responses, andhealth-related issues. Each separate issue conveyedin a single news article is therefore subject to users’selective attention. It follows that there is a likelihood that

VAPING IN THE NEWS 27

normative information is not retained and processed whenpeople read news articles. It may then fail to influence users’normative perceptions. Even if people can recall prevalenceinformation, their interpretations of social norms may beconfounded by personal experience, surrounding environ-ment, and pre-existing beliefs. Therefore, testing the effect ofnormative information embedded in news articles on read-ers’ perceptions will contribute to norm-building theory inthe context of routine mass media exposure.

H1: e-Cigarette news articles containing prevalenceinformation on e-cigarette use will affect readers’ per-ceived descriptive norms, such that those who reade-cigarette news articles that contain high-prevalenceinformation on average will have significantly higherdescriptive norm perceptions about e-cigarette use thanthose who read news articles that contain low-prevalence information.

To understand the absolute changes from the baselineproduced by prevalence information, the followinghypotheses are put forth:

H2a: Those who read e-cigarette news articles thatcontain high-prevalence information on average havesignificantly higher descriptive norm perceptions aboute-cigarette use than those who read news articles thatdo not contain any explicit prevalence information.

H2b: Those who read e-cigarette news articles thatcontain low-prevalence information on average willhave significantly lower descriptive norm perceptionsabout e-cigarette use than those who read news articlesthat do not contain any explicit prevalence information.

The exposure dosage of normative information

The focus theory of normative conduct emphasizes theimportance of norm salience in affecting behavior.9

Considering the possibility that normative informationembedded in news articles may be obscured by therichness of the news content, the present study alsoexamines whether increasing the salience of normativeinformation during information reception and proces-sing influences perceived descriptive norms. Zillmannsuggests that frequently activated cognitive schemataon social perceptions under conditions related tosome level of ambiguity (in this case, perceived descrip-tive norms) may influence social judgments of anissue.48 The literature in mass communication has indi-cated that news stories can affect the salience, or enact-ment, of a cognitive schemata depending on how much

news users have been exposed to.49 In addition, healthcommunication researchers have demonstrated thatincreasing exposure to consistent media messages influ-ences the formation of perceptions and attitudesthrough learning and memorization.50 Health cam-paigns that use mass media messages are advised tonot only ensure audience reach but also sufficient fre-quency of exposure to influence the targetaudience.51,52 Therefore, increasing the exposuredosage of normative information in news articles islikely to enhance normative perceptions.

H3: News articles that include double doses of norma-tive information have a greater influence on descriptivenorm perceptions compared to their single-dosecounterparts.

In addition, we are interested in understanding hownormative directions and exposure dosage may interactto influence descriptive norm perceptions:

RQ1: Are there any interaction effects between norma-tive directions (ie, high vs low prevalence) and expo-sure dosage (ie, single vs double dosage) in affectingdescriptive norm perceptions about e-cigarette use?

The moderating role of behavior status

Research has found that future tobacco-related product useintention is associated with past smoking and vapingexperience.34,53 Adolescents with experience in cigarettesmoking and e-cigarette vaping were found to be morelikely to use e-cigarettes than those with noexperience.2,54,55 The influence of behavior status on per-ceived descriptive norms as a result of news exposure hasnot been examined in the literature. However, research hasconcluded that people’s learning from news content isinfluenced by their engagement in making a mental con-nection between new information they receive froma media stimulus and information from past experiencesthat was already stored in their minds.45 Advertisingresearch has found that adolescents who experimentedwith cigarettes were more likely to attend to advertisedtobacco products.56 Thus, those who had experience ofsmoking and/or vaping may have an attention bias towarde-cigarette use normative information. In addition, pre-vious smoking and vaping trials likely provide individualswith experiential knowledge about peer e-cigarette use pre-valence through their interpersonal networks. Such experi-ential knowledge enables news users to engage in issue-relevant thinking,57 which is likely to increase accessibilityand recall of related behavioral information. Thus, the

28 H. T. DUONG AND J. LIU

current research attempts to determine whether ever vap-ing and smoking experience may moderate the news-induced descriptive norm perception formation.

H4: Ever vaping and smoking experience moderate theassociation between news exposure and perceiveddescriptive norms about e-cigarette use such that thedescriptive norm perceptions produced by news con-tent will be more pronounced among (a) individualswith ever vaping experience compared to those with novaping experience and (b) those with ever smokingexperience compared to those with no smokingexperience.

Implicit normative cues conveyed by news

Social norm theorists suggested that people are motivatedto gain information about what others are doing to helpwith decision making.20 People can also sense descriptivenorms through various informational cues.13 Fiske andTaylor theorized that human beings, in general, are cogni-tive misers, and they may use mental shortcuts to makegeneralizations on what is typical in their surroundings.58

Tankard and Paluck explained that this motivation derivesfrom the desire to be accurate about events, facts, and socialappropriateness.20 Therefore, peoplemay act as naïve scien-tists as they try to make sense of social phenomena.59

Although news articles were found to shape public nor-mative perceptions by providing explicit information onothers’ behavior choices,60 implicit behavioral cues andinstitutional cues depicted in mass media may also influ-ence normative perceptions.20 Behavioral cues refers tobehaviors (or lack thereof) performed by social others inthe surrounding environment or through mediaportrayals.8,61 Institutional cues come from institutionssuch as government, schools, and mass media.20

Institutions’ acts and innovations can communicatenorms, because they may be perceived to represent orserve the interest of a group. For example, after the issuanceof a cigarette ban on campus, students may infer that fewerpeople smoke on campus. Mass media may be perceived asa carrier of descriptive norms due to people’s beliefs that themedia reports what the public is interested in or what thepublic opinion is.20 Hence, mass media may inadvertentlysend normative signals throughmerely reporting on certainarguments.62 However, there is a surprising paucity ofhealth communication research to investigate what cuesor traces people identify as normative cues in news articlesthat do not contain explicit prevalence information. Thedearth of research on this topic presents both challenges tounderstanding how social norms can be formed throughroutine media consumption and opportunities to change

behaviors viamassmedia. To explore this phenomenon, wedesigned an open-ended question in our survey instrumentthat allows participants to qualitatively express theirthoughts related to how they formed normative percep-tions on e-cigarette use in the absence of prevalence infor-mation in the news.

RQ2: Through what sources or indicators do peopleinfer descriptive norms from e-cigarette-related newsarticles that do not contain any explicit prevalenceinformation?

Method

Participants

A total of 298 college students were recruited througha research subject pool at a large public university inthe United States. The participants received class creditfor their participation. There were more males (49.0%)than females (39.3%) in the sample, with 11.7% notreporting gender. The average age was 19.23 years(SD = 1.39). The majority described themselves asCaucasian (69.2%), with the remainder identifying asAfrican American (6.2%), Asian (11.7%), Hispanic(7.6%), and other (5.3%). About half of the participantsreported having smoked (54%) or vaped (49.3%), evenone or two puffs.

Procedure and design

This study employed a 2 normative direction (high vslow prevalence) × 2 exposure dosage (single vs doubledose) between-subjects factorial design, with a fifthgroup serving as the control condition. In the 4 treat-ment conditions, we varied the direction and amountof e-cigarette-related normative information (ie, single-dose high-prevalence vs double-dose high-prevalencevs single-dose low-prevalence vs double-dose low-prevalence) contained in the stimuli. In the controlcondition, no normative information was presented inthe stimuli. Participants were invited to an onlineQualtrics survey. They were first provided with infor-mation about the study and asked to provide informedconsent if they chose to participate. They were thenrandomly assigned to the experimental conditions,where they were presented with one 1 of 10 randomlyselected news articles about e-cigarettes (see detailsbelow) within each condition. Next, participants com-pleted a set of questions measuring perceived e-cigar-ette use descriptive norms, prior smoking and vapingbehaviors, and demographic variables. Immediately

VAPING IN THE NEWS 29

following the descriptive norm perception question,participants were asked to provide explanations fortheir ratings on this question with an open-ended ques-tion. The entire study took approximately 15 minutesto complete. Participants were debriefed upon comple-tion, thanked for their participation, and dismissed.

Stimulus materials

To address the potential case-category confoundingissue, we created more than one news articles(N = 10) for use in the study.63 Thus, even for partici-pants in the same treatment conditions, the news articlethat was shown to them would be randomly chosenfrom the pool of the 10 articles. Thus, the results wouldbe less likely to be confounded by some unexpectedcharacteristics associated with a single news article sti-mulus. All 10 news articles were created by modifyingreal news articles from online websites of top newsoutlets, such as the Wall Street Journal, HuffingtonPost, the New York Times, The Guardian, The Age,and Reuters. The topics of the news articles wererelated to the debates surrounding the benefits andrisks associated with e-cigarette use, including asa smoking cessation aid, general health safety, long-term effects (both health and social impacts), vapingin the workplace, vaping in public places, secondhandvaping, vaping etiquette, public opinion about e-cigar-ettes, and e-cigarette flavors.

All 10 news articles were created to be of equivalentlength with a neutral photo of an e-cigarette appendedto its side (randomly chosen from a pool of similarphotos), to maximally resemble the formatting andconvention of online news websites, thus enhancingthe materials’ ecological validity. All photos were con-trolled for normative, behavioral, and gender cues byshowing only the image of a gender-neutral hand hold-ing an e-cigarette. The valence of the news articles washeld balanced. That is, they were designed to contain anequal presence (quantity and description length) ofpositive and negative e-cigarette-related topics. Thenews headlines were also created to be neutral andbalanced so that they would not establish frames ofreference that may convey normative or preferenceimplications.64 Specifically, the headlines were eithercrafted as questions (eg. “Are e-Cigarettes a PublicHealth Hazard or the Key to Quitting Smoking?”) orstated in a neutral tone (eg, “e-Cigarettes: Where WeStand Now”). Participants were told that they wouldread a news story, with no reference to the news

agencies. The original 10 articles did not contain anynormative information.

To manipulate normative direction and exposuredosage, we collected true statements of normativeinformation about e-cigarette use to be incorporatedinto the 10 news articles from the Centers for DiseaseControl and Prevention website65 and news articlespublished by the same news outlets that we used tocollect our stimulus materials. A pool of 10 normativestatements (5 containing low-prevalence informationand 5 containing high-prevalence information) wasobtained. Some examples of low-prevalence statementsinclude “Only 10% of U.S. adults vape, according toa recent online poll,” or “As it is a pretty new producton the market, it is relatively new to users and onlya few have tried e-cigarettes.” Examples of high-prevalence statements are “In recent years, e-cigaretteuse by youth and young adults has increased” and“e-Cigarettes are now the most commonly used tobaccoproduct among youth in the United States.” We nextrandomly chose and assigned these statements based onthe design of each treatment condition. Specifically, ineach of the 10 articles for the high-prevalence andsingle-dose condition, one high-prevalence statementwas randomly selected out of the pool of 5 to beincluded as the last sentence of the first paragraph. Inthe high-prevalence and double-dose condition, 2 ofthese statements were randomly selected from thepool and added to the end of the first and last para-graphs respectively for each of the 10 articles. The samemanipulation using low-prevalence statements wasconducted for the low-prevalence conditions. In thecontrol condition, the 10 original articles that containedno explicit normative information were used (seeAppendix for a set of news stimuli associated with thesame original news article used in different conditions).

Measures

Descriptive norm perceptions about e-cigarette useDescriptive norm perceptions were assessed by askingparticipants to rate the prevalence of e-cigarette use inthe real world on a 7-point Likert scale, ranging from 1(very low) to 7 (very high).

Ever smoking experienceEver smoking experience was assessed with the ques-tion, “Have you ever smoked, even one or two puffs?”The responses were recorded on a dichotomous scalewhere 0 = no and 1 = yes.

30 H. T. DUONG AND J. LIU

Ever vaping experienceEver vaping experience was assessed by one question,“Have you ever used an e-cigarette, even one or twopuffs?” The responses were recorded on a dichotomousscale where 0 = no and 1 = yes.

DemographicsDemographics included age, sex (male/female), andrace/ethnicity (African American, Asian, Caucasian,Hispanic, other).

Sources of normative inferenceIn the control condition, an open-ended questionimmediately following the descriptive norm perceptionquestion asked participants to indicate the sources orindicators on which they formed their descriptive normperceptions: “Which part of the article makes you thinkthe prevalence of e-cigarette use is [insert their answerto the descriptive norm perception question]? You caneither explain in your own words, or quote the relevantcontent from the article.”

Data analysis

SPSS 24 was used for statistical analysis. Data wereinitially screened and examined for normality and out-liners. No age difference, F(4, 291) = 0.630, P = .64, orgender difference, χ2(4) = 1.963, P = .85, was observedacross conditions. Because our focal manipulation wasthe absence, presence, and dose of prevalence informa-tion statements, which were considered intrinsic mes-sage features, manipulation checks were notnecessary.66,67 Descriptive norm perceptions of e-cigar-ette use were outcomes induced by the message stimuli.

To examine the main (H1 and H3) and interactioneffects (RQ1) of the 2 factors (ie, normative directionand exposure dosage), we first conducted a 2-way ana-lysis of variance (ANOVA) within the treatment con-ditions. Then two planned contrasts (high prevalence vscontrol and low prevalence vs control) were performedfollowed by a one-way ANOVA with a 3-conditionindependent variable (high prevalence conditions, lowprevalence conditions, and control) and e-cigarettedescriptive norm perceptions as the dependent variable.To test H4, we conducted moderator analyses withinthe treatment conditions to examine whether eversmoking or vaping experience would influence theeffects of our experimental manipulation (high preva-lence vs low prevalence) on perceived e-cigarettedescriptive norms.

To answer RQ2, we focused on the control condition(n = 55). We analyzed the open-ended responses usingsystematic categorization and coding.68 Using the

coding scheme, each of the authors reviewed theresponses iteratively to identify categories of responsesby the forcefulness, recurrence, and repetition of thedata.69 We then discussed the themes to refine andreorganize the responses according to the identifiedpatterns within categories.68 Finally, we reread theresponses to verify the compatibility between thethemes and the actual expressions in the data.

Results

Hypothesis testing

A 2-way full-factorial ANOVA within the treatmentconditions was first conducted, with normative direc-tion and exposure dosage as fixed factors and perceiveddescriptive norms of e-cigarette use as the dependentvariable. The overall model was significant, F(3,220) = 674.72, P < .001, ηp

2 = 0.93. Normative directionwas found to significantly influence perceived descrip-tive norms of e-cigarette use, F(1, 220) = 174.60,P < .001, ηp

2 = 0.44, such that participants in the high-prevalence conditions (M = 5.58; SD = 1.09) reportedsignificantly higher e-cigarette use prevalence percep-tions than those in the low-prevalence conditions(M = 3.27; SD = 1.53; P < .001). H1 was supported.Although the main effect of exposure dosage (H3) wasnot found to be significant in the in the omnibus test, F(1, 220) = 1.06, P = .30, ηp

2 = 0.01, a significant inter-action (Figure 1) between the normative direction andexposure dosage was observed, F(1, 220) = 8.76, P < .01,ηp

2 = 0.038 (RQ1). Simple effects analysis indicated thatin low-prevalence conditions, double dosage signifi-cantly lowered descriptive norm perceptions comparedto that produced by a single dose of low-prevalenceinformation (P < .05), but double doses of high-prevalence information did not significantly increasedescriptive norm perceptions compared to that in thesingle-dose high-prevalence condition (P = .66).

H2 predicted that those who read e-cigarette-relatednews articles containing prevalence information wouldproduce significantly higher (H2a) or lower (H2b)descriptive norm perceptions about e-cigarette usecompared to baseline (ie, descriptive norm perceptionsof those who read news articles that did not contain anyexplicit normative information). The one-way ANOVAtest results showed a significant omnibus effect, F(2,277) = 93.76, P < .001, ηp

2 = 0.40. Planned contrastssuggested that participants in the high-prevalence con-ditions (M = 5.58; SD = 1.09) reported significantlyhigher e-cigarette use prevalence perceptions thanthose in the control conditions (M = 5.07; SD = 1.17;P < .05), whereas participants in the low-prevalence

VAPING IN THE NEWS 31

conditions (M = 3.27; SD = 1.53) reported significantlylower prevalence perceptions than those in the controlcondition (P < .001). Thus, H2 was supported. SeeTable 1 for means and standard deviations of thedescriptive norm perceptions in all conditions.

Hypothesis 4 predicted the moderating effects ofever vaping and smoking experience on the relationbetween news exposure and perceived descriptivenorms about e-cigarette use. Moderator analysis resultsindicated that neither ever vaping, F(1, 204) = 1.09,P = .40, ηp

2 = 0.003, nor ever smoking, F(1,205) = 1.04, P = .31, ηp

2 = 0.005, was found to bea significant moderator. On average, those who neverused e-cigarettes (M = 4.39, SD = 0.13) formed descrip-tive norm perceptions similar to those of ever users(M = 4.41, SD = 0.12). Similarly, those who neversmokerd (M = 4.30, SD = 0.14) reported similar levelsof perceived descriptive norms compared to ever smo-kers (M = 4.46, SD = 0.11). Thus, H4 was notsupported.

Qualitative data analysis

RQ2 asked how participants in the control conditionformed descriptive norm perceptions for e-cigarette use

based on what they read in the news articles, which didnot contain explicit normative information and hada balanced or neutral tone toward e-cigarettes. Thequalitative analysis results converged on two salientthemes: institutional signals and misattributed beha-vioral cues. Each theme identified was endorsed bya minimum 32% occurrence in participants’ responses.

Institutional signalsAccording to Tankard and Paluck, institutions such asuniversities, governments, and mass media can influ-ence normative perceptions by their credibility andperceived legitimacy to represent groups’ interests.20

Interestingly, our analysis of participants’ responsesshowed that institutional signals emerged in differentforms. We found that participants tended to attributea behavior being reported in the news as having highsalience, and thus high prevalence, in the public. Basedon the fact that professional journalists and mediaagencies decided to report e-cigarette-related news,they inferred that use of e-cigarettes must be a salientand important social issue. Participants also respondedthat although e-cigarette use was neither explicitly sup-ported nor objected to, the news article insinuateda negative connotation that led them to estimate highprevalence of e-cigarette use. Though the news valencewas by design held balanced through an equal presen-tation of positive and negative e-cigarette-relatedtopics, some frequently used language appearing in ane-cigarette news report (eg, smoke, cigarettes, chemi-cals, etc) may have elicited negative impressionsabout e-cigarettes through unwittingly creatinga misconception about the resemblance between smok-ing and vaping. For example, one participant stated,“The article is describing a new form of ‘smoking’ andfears of e-cigarettes are used as a stalking horse bytobacco companies, who want to promote the habit.”

Another institutional signal that influenced partici-pants’ normative perceptions was the mention ofe-cigarette-related research in the news. Participantsexplained that if institutions were already investingresources to understand the health consequences ofe-cigarette use, then there the product must be widelyused. Mentions of research evidence coming from dif-ferent countries were used by participants to infer thate-cigarette use is a global issue. One participant wrote,“The prevalence of e-cigarette use must be somewhathigh if officials, such as Carlos Corvalan, fromEnvironmental Health Australia is concerned about it.Based on this article, I would assume thatEnvironmental Health Australia is a large governmententity.” Moreover, participants used institutionalactions, such as when an institution introduced a new

Figure 1. Interaction between normative direction and expo-sure dosage on perceived descriptive norms of e-cigarette use.

Table 1. Means and standard deviations for perceived descrip-tive norms of e-cigarette use.Experimental condition n Mean SD

Low prevalence/single dose 59 3.61 1.52Low prevalence/double dose 56 2.91 1.47High prevalence/single dose 54 5.41 .90High prevalence/double dose 55 5.75 1.24No prevalence information (control) 56 5.07 1.17

32 H. T. DUONG AND J. LIU

e-cigarette-related regulation or policy, to infer per-ceived descriptive norms. For example, after readinga news article that discussed vaping in the workplace,one participant stated, “The fact that there is a need fororganizations to start forming policies on the usage ofe-cigarettes demonstrates that the prevalence of e-cigar-ettes is high.”

Misattributed behavioral cuesWe found that participants paid attention to languagethat characterized the state of the e-cigarette debates toinfer the prevalence of e-cigarette use. Three partici-pants stated that because the news articles stated thate-cigarette use was the subject of hot debate, they con-cluded that vaping must be trendy and attractive toothers. Some participants explained that a large numberof people must use e-cigarettes because the news articlementioned the “diverse range of flavors” and “most ofthe flavors are safe chemicals often added to foods.”This means that normative information about the richfeatures of e-cigarettes, such as their diverse flavors,were used to make inferences about e-cigarette useprevalence. Words that were used to describe therange of e-cigarette flavors, such as diverse, variety,and different, were picked up by the participants andmisattributed as evidence of the popularity of the beha-vior. Moreover, one participant suggested that becausethe news reported that e-cigarettes were an “alternativeto smoking,” vaping should be just as popular as smok-ing. Another participant suggested, “This phenomenonhas had a relatively high level of interaction and invol-vement with society, if it has a commonly used nick-name and its users are also referred to by this name.”

The analysis of the open-ended responses alsorevealed that participants used firsthand knowledge ofe-cigarettes to form their perceived descriptive norms.For example, participants said that they had seen othersusing e-cigarettes on a college campus, at a workplace,or in a neighborhood. They also used their prior obser-vations of others’ smoking behaviors to infer e-cigaretteuse norms. One participant commented, “So manypeople smoke cigarettes and with a product in thesame market, I assume many people use e-cigarettesas well.”

Discussion

This research investigated the influence of exposure tonormative information embedded in news articles onindividuals’ descriptive norm perceptions aboute-cigarette use among college-aged young adults.Results from the experiment supported our hypothesisthat normative information contained in the news

articles can effectively influence participants’ percep-tions of e-cigarette use prevalence, in both normativedirections. Findings also indicated that dosage of nor-mative information played a significant role in influen-cing perceived descriptive norms in the low-prevalenceconditions but not in the high-prevalence conditions,such that double doses of normative information in thelow-prevalence condition significantly reduced per-ceived descriptive norms compared to that in the sin-gle-dose condition. This effect, however, was not foundin the high-prevalence conditions. The data also indi-cated that the influence of news article exposure onperceived descriptive norms was not dependent onwhether or not individuals had ever vaped or smoked.The results of the qualitative analysis showed that indi-viduals utilized institutional and misattributed beha-vioral cues to infer e-cigarette use prevalence in theabsence of explicit normative information.

The study sheds light on the process of descriptivenorm perception formation through exposure to newsarticles. Despite scholars’ postulation of the influence ofmass media on social norm formation, it is unclearwhether prevalence information contained in news arti-cles indeed affects descriptive perceptions and howsuch influence operates.13 If the news does have aneffect on social norm formation, it is also unclearwhether the directions of norms (low- and high-prevalence information) conveyed in the news wouldcarry the same weight in influencing social norm for-mation. Mass communication theories about howexposure to mass media affect normative perception,such as cultivation theory, suggest a norm formationmechanism in which descriptive norms are graduallyformed overtime.70 This experiment, however, showedthat the effect of news media can be a one-off anddirect stimuli-response reaction, in which normativeperceptions of e-cigarette use were successfully formedand reported.

The results of the experiment showed that the nor-mative directions (low- and high-prevalence informa-tion) conveyed by the news articles can effectivelyinfluence individuals’ descriptive norm perceptions.The exposure dosage factor (single and double doses),however, was found to only enhance social norm for-mation in low-prevalence conditions. Particularly, indi-viduals who were exposed to news articles with 2 dosesof low-prevalence information perceived significantlyfewer people using e-cigarettes, compared to thosewho read news articles containing only one dose. Thisfinding suggests that low-prevalence information men-tioned in the news articles may carry greater weightthan information of high prevalence in influencingpeople’s descriptive norm perceptions. Such “negation

VAPING IN THE NEWS 33

bias” echoes previous studies that examined descriptivenorm perception formation process through exposureto online user-generated comments.60 Research hasfound that negation of implementing a behaviorreceived more attention from individuals during eva-luation formation and information recalled.71,72 Thelikely existence of negation bias suggests that HealthEducators may benefit from increasing the dosage oflow-prevalence information in messages to maximizeeffects of social norm appeals on normative perceptionsand behavior change.

Our study provided insights into how individualsmay form their descriptive norm perceptions fromnews consumption, in the absence of explicitly com-municated prevalence information. Indeed, the findingsof the qualitative analysis revealed that individuals capi-talized on institutional and behavioral cues from massmedia content to interpret what was normative insociety. This finding provided further empirical evi-dence to the theorization of the sources of socialnorms perception formation.8,20 People take informa-tion delivered by mass media agencies and actionsperformed by professional organizations as indicatorsof social norms. Specifically, when news stories reporton a health-related behavior, readers assume that thebehavior must be significant and prevalent. In addition,institutional actions, such as allocating resources forresearch and regulation, were perceived as signals ofprominence as well. This suggests that the currentmedia coverage of the debates on scientific evidenceof e-cigarette use and how to regulate it are likely tohave an impact on media users’ prevalence estimationabout vaping.

We observed a spillover effect related to the seman-tic knowledge that influenced individuals’ heuristicjudgments of descriptive norms. We found that parti-cipants tended to transfer the product attributes tobehavioral attributes for descriptive norm formation,particularly when descriptions of products attributeswere positively perceived. That is, the description ofe-cigarettes as having a diverse range of flavors anddesigns initiated a positive impression of the product,meaning that the product is attractive and popular toconsumers. This description, which was commonlyused in e-cigarette news articles, appeared to have aneffect on news readers’ subsequent estimations ofe-cigarette use norms. This is consistent with previousresearch on spreading activation effects, in which asso-ciative relatedness of information influenced cognitiveelaboration and recall.73,74 Research in health commu-nication has also found a health halo effect in productlabeling, such that products titled with positive infor-mation heightened cognitive accessibility and judgment

of the overall healthfulness perceptions.75 Thus, wesuspected that a mediation mechanism takes placewhereby product attributes indirectly influence socialnorm perceptions via behavioral attributes. Given thisfinding, it would be informative for future studies tofurther examine this potential mediation pathway.

The results of the test for Hypothesis 4, which pre-dicted the moderating effect of ever smoking and vap-ing experience on the association between newsexposure and descriptive norm formation, were corro-borated by the findings from the qualitative analysis.Specifically, the quantitative analysis indicated thatHypothesis 4 was not supported, and the qualitativefindings showed that participants who have evervaped or smoked did not rely on their own behaviorto generate normative perceptions. We found that theyrelied on their observations of others’ vaping and uti-lized this memory to estimate descriptive norms. Thecombined findings presented here point to the role ofmass media and reference others, rather than one’s ownprior experience, in informing one’s judgment aboutthe prevalence of a behavior. Research has indicatedthat people made less use of their own experience toinfer normative cues when media cues were present.75

This finding further consolidated the significant influ-ence of mass media on individuals’ normative percep-tions of e-cigarette use.34,39

This research has limitations. The study measuredthe outcome variables immediately after paticipants’exposure to the stimuli materials, which may not beinformative about the long-term effects of media newsstories on social norm perceptions. The use of singleitems to measure the dependent variable may be subjectto reliability issues. It would be a fruitful future direc-tion to include multiple items for the measured depen-dent variables and assess the long-term effect of newsexposure on descriptive norm perceptions. In addition,our attempt to qualitatively analyze news readers’ inter-pretations of social norm sources was limited in scaleand depth. However, to the best of our knowledge, ourefforts are among pioneering endeavors that aim todecompose this phenomenon with concrete under-standings above and beyond the quantitative results.In this sense, the results do provide some ideas forfuture studies where more systematic qualitative inves-tigation of the subject matter will be conducted.

Translation to Health Education Practice

This study found evidence for the role of the newsmedia in influencing individuals’ normative percep-tions about a scientifically contested health behavior,for which descriptive norms are often more influential

34 H. T. DUONG AND J. LIU

than they are for well-established behaviors.77,78 Thestudy results, when translated to the real world, revealthat people can successfully form descriptive norms fore-cigarette use based on the explicit prevalence infor-mation as well as other implicit informational cuesincluded in the news. The TNSB has indicated thatdescriptive norms lead to more consumption oftobacco products. Although the health effects ofe-cigarette use are still scientifically divisive, researchhas shown that e-cigarette use can be a gateway tosmoking renormalization. The Centers for DiseaseControl and Prevention also warns that e-cigarettesare not safe for youth, young adults, and adults whodo not currently use e-cigarettes.1

Social norm campaigns have focused more on craftingads with persuasive intent or interpersonal communicationthan the influence of individuals’ daily news consumptions,which is also an influential source of normative perception.Newsmedia, which presumably have much greater societalinfluence and exist in people’s day-to-day life, may haveunintentionally increased normative perceptions of riskbehaviors through highlighting implicit and explicit high-prevalence information. Given the pervasiveness of mediacontent reporting e-cigarette debates and the fact thatperceived descriptive norms often guide individuals’ beha-vior decisions, anti-tobacco Health Educators should con-sider paying close attention to normative cues related toe-cigarette use delivered through people’s routine mediaencounters. Although it is impractical to try to changejournalists’ reporting practices, being cognizant of themechanism of normative perception formation throughnews exposure may help Health Educators identify impor-tant risk factors hindering their social change efforts.Health Educators should carry out formative research toexamine normative perceptions of e-cigarette use. In casee-cigarette use norms are inflated, norm-debiasing strate-gies should be adopted to readjust college students’ norma-tive misperceptions of e-cigarette use with actual norms.79

Such an approach helps prevent inflated descriptive normperceptions triggered by exposure to normative mediacontent. As to social norm message design, this researchsuggests that social norm interventions should considerincreasing the dosage of low-prevalence information tomaximize the effect of normative appeals. Further researchto replicate and expand these findings will generate moreinsights into understanding the process of normative per-ception formation and how to optimally leverage its potentpower to influence desirable behavior change.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Hue Trong Duong http://orcid.org/0000-0001-8742-1040

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Appendix

(B). Example news stimuli with double doses of low-prevalence information

(A). Example news stimuli with no prevalence information

38 H. T. DUONG AND J. LIU

(C). Example news stimuli with double doses of high-prevalence information

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