Stephanie R. Land and Wen-Ying Sylvia Chou

National Cancer Institute, USA

Tobacco control efforts are regularly complicated by the entry of new tobacco products into the marketplace. New products are often not well understood by the public, including members of the target markets, healthcare professionals, and community leaders. For example, we may lack information about toxicant exposures and negative health effects associated with a new product’s use, the product’s role in causing or treating addiction, and peer attitudes toward the product. As people develop early impressions of a new and unfamiliar product, language, including words and metaphors, used by both public health communicators and industry marketers play a crucial role in shaping public perceptions and attitudes. One such word, popular, has been used in many instances to describe the uptake of electronic cigarettes and waterpipes by adolescents and young adults. However, the use of this term to describe the prevalence of health risk behaviors such as the use of tobacco products may have unintended negative consequences.

“Popular” has several definitions, among them, “suitable to the majority,” “indicative of the understanding and taste of the majority,” “widely accepted,” and “commonly liked or approved.” In the context of youth culture, the Urban Dictionary describes “popular kids” as having features such as “rich, good looking, heavily involved in school, funny”, contributing to a connotation of desirability. Describing tobacco products, such as electronic cigarettes or waterpipes, as “popular” may create or perpetuate an image of the product as being suitable, accepted, liked, and approved. In reality, “suitable”, “accepted”, “liked”, and “approved” belie the addictive nature of these products. The regular and ongoing use of tobacco products is not sustained because those products are accepted, but rather because they are addictive.

A cursory internet search yielded many examples of the term “popular” being used in communications to broad audiences about new tobacco products. For example, the student newspaper of the University of Pittsburgh (The Pitt Chronicle) headlined an article as “Hookah Smoking Rising, Surprisingly Popular Among College Students.” U.S. News & World Report, whose broad public readership includes parents, teachers, clinicians and public health officials, recently headlined an article “E-Cigarettes Gain Popularity Among Teens.” Other examples include communications from government agencies and public health organizations.

It is well established that individuals are more likely to engage in behaviors they view as common or normative. We believe that exposure to language suggesting that tobacco use – and in particular use of electronic cigarettes or waterpipes – represents a “popular choice” of many may promote uptake of the product, especially by youth. Studies have demonstrated that adolescents are likely to overestimate the prevalence of risk behaviors among peers; the implication that tobacco products are “widely accepted” may reinforce this misperception. Furthermore, correcting perceived norms can lead to healthier behavior. In addition to the potential influence on would-be users, there are non-user audiences for whom formative impressions are consequential. Parents, teachers, and public officials exposed to positive connotations of a “popular” product may be less likely to react with concern and intervene with a user or to create policies and practices for prevention. It’s also possible that the connotations make them perceive the behavior as normative or intractable, and therefore conclude that it is too late to intervene.

We believe that scientists, clinicians, and public health practitioners should carefully consider the implications of using the term “popular” to describe tobacco product use, and consider avoiding using the term. Simple factual language, such as “increasing numbers of youth have tried electronic cigarettes” or use of the more scientific term “prevalent” may help avoid unintended positive connotations. Widespread and growing use of a tobacco product can be referred to as an “epidemic” and the product itself as a “disease vector”. In conclusion, in order to remain sensitive and responsive to the constant evolution of the tobacco use landscape and novel marketing strategies, it is important to be cognizant of our word choice and potential unintended consequences. Just as the public health and scientific community would not likely employ the term popular to describe opioid use; neither should we use this term to describe use of tobacco products. In short, word choice matters.

Stephanie Land is a Program Director and Statistician at the Tobacco Control Research Branch, and Wen-Ying Sylvia Chou a Program Director at the Health Communication and Informatics Research Branch, in the Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland, USA.

Disclaimer: The opinions expressed in this article are the authors’ own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States government.