JMIR Publications

ABSTRACT

Background:

Youth e-cigarette use rose sharply between 2013 and 2024 in the United States, prompting widespread prevention campaigns at national, state, and local levels. Many of these campaigns encountered online opposition, sometimes leading to message distortion or campaign withdrawal.

Objective:

This study compares opposition tactics on Twitter (now X) and TikTok to inform platform-specific prevention strategies.

Methods:

We conducted cross-platform surveillance of e-cigarette prevention campaigns using representative campaigns such as The Real Cost (national), Still Blowing Smoke (California), and Vaping Truth (Chicago). Using machine learning (F1=0.90) and human labeling (Gwet's AC1>0.81), we analyzed 310,207 Twitter posts (2014-2020) and 3363 TikTok videos (2020-2023). Analyses examined message prevalence, narrative frames, and engagement patterns, with particular attention to oppositional content.

Results:

On Twitter, opposition peaked during regional campaigns (up to 99.0% of related tweets) and was amplified by clusters of active accounts, including some featuring links to commercial promotion and advocacy. Dominant narrative frames included questioning the credibility of health authorities, boomerang effects of prevention advertisements, vaping rights, and product promotion. On TikTok, opposition (3.5% of campaign-related posts) was decentralized and entertainment-driven, primarily characterized by humor/entertainment (65.7%), mockery of prevention campaigns (44.4%), and ironic/hyperbolic vaping references (27.8%). About 10% of TikTok accounts posting prevention content about e-cigarette use were health-related. Despite fragmented hashtag use, prevention campaign posts consistently achieved higher average engagement than oppositional content.

Conclusions:

Opposition to youth e-cigarette prevention campaigns reflects distinct platform architectures. Twitter opposition was highly coordinated and amplified by commercial and advocacy accounts, especially during regional campaigns. TikTok opposition was decentralized and humor-driven, aligning with the platform’s entertainment-oriented algorithm. These patterns illustrate how strategic co-optation of hashtags and hashtag drift disrupted campaign coherence. Public health strategies must be evidence-based and platform aware: on Twitter, reinforcing narratives through credible health sources may counter coordinated opposition, while on TikTok, creator partnerships and platform-native content (e.g., remixable PSAs, duets) can improve resonance with youth audiences. Greater platform accountability and transparency are also needed to ensure prevention content is not disadvantaged relative to commercial promotion.