Our research provides social scientists with areas of inquiry in tobacco-related health disparities in young adult women and opportunities for intervention, as Instagram may be a powerful tool for the public health surveillance of smoking behavior and social norms among young women. Social media has fundamentally changed how to engage with health-related information. Researchers increasingly turn to social media platforms for public health surveillance. Instagram currently is one of the fastest growing social networks with over 53% of young adults (aged 18-29) using the platform and young adult women comprise a significant user base. We conducted a content analysis of a sample of smoking imagery drawn from Instagram's public Application Programming Interface (API). From August 2014 to July 2015, 18 popular tobacco-and e-cigarette-related text tags were used to collect 2.3 million image posts. Trained undergraduate coders (aged 21-29) coded 8,000 images (r = .91) by type of artifact, branding, number of persons, gender, age, ethnicity, and the presence of smoke. Approximately 71.5% of images were tobacco-relevant and informed our research. Images of cigarettes were the most popular (49%), followed by e-cigarettes (32.1%). "Selfies while smoking" was the dominant form of portrait expression, with 61.4% of images containing only one person, and of those, 65.7% contained images of women. The most common selfie was women engaged in "smoke play" (62.4%) that the viewer could interpret as "cool." These "cool" images may counteract public health efforts to denormalize smoking, and young women are bearing the brunt of this under-the-radar tobacco advertising. Social media further normalizes tobacco use because positive images and brand messaging are easily seen and shared, and also operates as unpaid advertising on image-based platforms like Instagram. These findings portend a dangerous trend for young women in the absence of effective public health intervention strategies.
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