Twitter Surveillance at the Intersection of the Triangulum.

Introduction A holistic public health surveillance approach can help capture the public's tobacco and marijuana-related attitudes and behaviors. Using publicly available data from Twitter, this is one of the first studies to describe key topics of discussions related to each intersection (e-cigarette, combustible tobacco, and marijuana) of the Triangulum framework. Method Twitter posts (n=999,447) containing marijuana, e-cigarette and combustible tobacco terms were collected from January 1, 2018, to December 23, 2019. Posts to Twitter with co-occurring mentions of keywords associated with the Triangulum were defined as an intersection (e-cigarettes and combustible tobacco, combustible tobacco and marijuana, e-cigarettes and marijuana, and marijuana, e-cigarettes and combustible tobacco). Text classifiers and unsupervised machine learning was used to identify predominant topics in posts. Results Product Features and Cartridges were commonly referenced at the intersection of e-cigarette and marijuana-related conversations. Blunts and Cigars and Drugs and Alcohol were commonly referenced at the intersection of combustible tobacco and marijuana-related discussions. Flavors and Health Risks were discussed at the intersection of e-cigarette and combustible-related conversations, while discussions about Illicit products and Health risks were key topics of discussion when e-cigarettes, combustible tobacco, and marijuana were referenced all together in a single post. Conclusion By examining intersections of marijuana and tobacco products, this study offers inputs for designing comprehensive FDA regulations including regulating product features associated with appeal, improving enforcement to curb sales of illicit products, and informing the FDA's product review and standards procedures for tobacco products that can be used with marijuana. Implications This study is the first to leverage the Triangulum framework and Twitter data to describe key topics of discussions at the intersection of e-cigarette, combustible tobacco, and marijuana. Real-time health communication interventions can identify Twitter users posting in the context of e-cigarettes, combustible tobacco, and marijuana by automated methods and deliver tailored messages. This study also demonstrates the utility of Twitter data for surveillance of complex and evolving health behaviors.