E-Cigarette Health Harm Awareness and Discouragement: Implications for Health Communication

INTRODUCTION

Evidence for the health harms of e-cigarettes is growing, yet little is known about which harms may be most impactful in health messaging. Our study sought to identify which harms tobacco product users were aware of and which most discouraged them from wanting to vape.

METHODS

Participants were a convenience sample of 1,872 U.S. adult e-cigarette-only users, cigarette-only smokers, and dual users recruited in August 2018. In an online survey, participants evaluated 40 e-cigarette harms from seven categories: chemical exposures, device explosions, addiction, cardiovascular harm, respiratory harm, e-liquid toxicity, and other harms. Outcomes were awareness of the harms ("check all that apply") and the extent to which the harms discouraged vaping (5-point scale; (1) "not at all" to (5) "very much").

RESULTS

Awareness of most e-cigarette harms was modest, being highest for harms in the device explosions category of harms (44%) and lowest for the e-liquid toxicity category (16%). The harms with the highest mean discouragement from wanting to vape were the respiratory harm (M = 3.82) and exposure to chemicals (M = 3.68) categories. Harms in the addiction category were the least discouraging (M = 2.83) compared with other harms (all p < .001). Findings were similar for e-cigarette-only users, cigarette-only smokers, and dual users.

CONCLUSIONS

Addiction was the least motivating e-cigarette harm, a notable finding given that the current FDA e-cigarette health warning communicates only about nicotine addiction. The next generation of e-cigarette health warnings and communication campaigns should highlight other harms, especially respiratory harms and the chemical exposures that may lead to health consequences.

IMPLICATIONS

E-cigarette health harms related to respiratory effects, chemical exposures, and other health areas most discouraged vaping among tobacco users. In contrast, health harms about addiction least discouraged use. Several countries have begun implementing e-cigarette health warnings, including the United States, and many others are considering adopting similar policies. To increase impact, future warnings and other health communication efforts should communicate about health harms beyond addiction, such as the effects of e-cigarette use on respiratory health. Such efforts should communicate that e-cigarette use is risky and may pose less overall risk to human health than smoking, according to current evidence.

The Power of Celebrity Health Events: Meta-analysis of the Relationship between Audience Involvement and Behavioral Intentions

Audience involvement processes - such as parasocial interaction and identification - may impact an individual's response to celebrity health events, yet to date, no synthesis of the literature exists. The present meta-analysis examined audience involvement processes and their influence on health behavior intentions in the context of celebrity health events. Fourteen studies (N = 5,718) met criteria and were analyzed using meta-analytic procedures. The weighted mean effect of the association between audience involvement and behavioral intentions was r = 0.20 (95% CI, 0.08-0.31, p <.001), indicating a statistically significant small-to-medium-sized positive association. Moderator analyses revealed that celebrity disclosures and events had greater effects than depictions of a media persona with a health condition; greater effects were also found for health behaviors not requiring a medical procedure. Our findings suggest that those who most feel a sense of attachment or affinity for a celebrity or media personae may be the ones who are most likely to modify their behavioral intentions in the wake of a celebrity health event. Results highlight the need for health practitioners to recognize the role of audience involvement in celebrity health events and to better assess how to harness these opportunities to promote healthy behaviors.

Understanding Why Pictorial Cigarette Pack Warnings Increase Quit Attempts

BACKGROUND

Our randomized trial found that pictorial cigarette pack warnings elicited more quit attempts than text-only warnings.

PURPOSE

In the current study, we sought to identify psychological mechanisms that explain why pictorial cigarette pack warnings change behavior.

METHODS

In 2014 and 2015, we recruited 2,149 adult smokers in NC and CA, USA. We randomly assigned smokers to receive on their cigarette packs for 4 weeks either a text-only warning (one of the USA's current warnings on the side of cigarette packs) or a pictorial warning (one of the USA's proposed text warnings with pictures on the top half of the front and back of cigarette packs).

RESULTS

Pictorial warnings increased attention to, reactions to, and social interactions about cigarette pack warnings (all p < .05). However, pictorial warnings changed almost no belief or attitude measures. Mediators of the impact of pictorial warnings included increased attention, negative affect, social interactions, thinking about the warning and harms of smoking, and intentions to quit (all p < .05). Analyses also found that pictorial warnings led to greater avoidance of the warnings, which was associated with more quit attempts (p < .05).

CONCLUSIONS

Pictorial warnings increased quit attempts by eliciting aversive reactions and by keeping the message vividly in smokers' minds. Contrary to predictions from several theories of health behavior, the warnings exerted little of their influence through changes in beliefs and attitudes and none of their influence through changes in risk perception. We propose the Tobacco Warnings Model based on these findings.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov identifier: NCT02247908; https://clinicaltrials.gov/ct2/show/NCT02247908.

Interest in Illicit Purchase of Cigarettes Under a Very Low Nicotine Content Product Standard

Significance

The US Food and Drug Administration (FDA) is considering a very low nicotine content (VLNC) product standard to substantially reduce nicotine in cigarettes. We examined whether learning about a potential VLNC standard increased smokers’ interest in illicit purchases of cigarettes with regular nicotine content if such a standard were adopted.

Methods

Participants were a national convenience sample of 1712 US adult smokers. In an online experiment, we randomly assigned smokers to view information about a new VLNC standard (experimental condition) or no information (control condition). The experimental condition explained that a VLNC standard would remove 95% of the nicotine in cigarettes and would require stores to only sell VLNC cigarettes. Then, the survey assessed smokers’ interest in purchasing regular cigarettes from three illicit sources.

Results

Smokers who learned about the VLNC standard were more likely to be very or extremely interested in purchasing regular cigarettes illicitly from a Web site compared to smokers in the control group (24% vs. 16%, p < .001). They were also more interested in illicitly buying cigarettes from a street vendor (19% vs. 13%, p < .001) and a store on an Indian reservation (28% vs. 22%, p < .05), compared to the control. The impact of learning about the VLNC standard on interest in illicit purchases did not differ by smoking frequency or current e-cigarette use.

Conclusions

A VLNC standard could increase smokers’ interest in illicit purchases of regular nicotine cigarettes. To prevent VLNC-induced illicit trade from undermining public health, FDA should consider proven measures such as track and trace for these products.

Implications

Little is known about how a VLNC cigarette standard would affect consumer interest in regular content cigarettes purchased from illicit sources (eg, the Internet). We found that smokers informed about a potential VLNC product standard had greater interest in illicit cigarette purchases, compared to controls. This suggests the importance of proactive measures accompanying a VLNC standard, such as track-and-trace cigarette packaging regulations and communication campaigns, in order to maximize the standard’s public health impact.

Cigarette Constituent Health Communications for Smokers: Impact of Chemical, Imagery, and Source

INTRODUCTION

Communication campaigns are incorporating tobacco constituent messaging to reach smokers, yet there is a dearth of research on how such messages should be constructed or will be received by smokers.

METHODS

In a 2 × 2 × 2 experiment, we manipulated three cigarette constituent message components: (1) the toxic constituent of tobacco (arsenic vs. lead) with a corresponding health effect, (2) the presence or absence of an evocative image, and (3) the source of the message (FDA vs. no source). We recruited smokers (N = 1669, 55.4% women) via an online platform and randomized them to one of the eight message conditions. Participants viewed the message and rated its believability and perceived effectiveness, the credibility of the message source, and action expectancies (ie, likelihood of seeking additional information and help with quitting as a result of seeing the message).

RESULTS

We found significant main effects of image, constituent, and source on outcomes. The use of arsenic as the constituent, the presence of an evocative image, and the FDA as the source increased the believability, source credibility, and perceived effectiveness of the tobacco constituent health message.

CONCLUSIONS

Multiple elements of a constituent message, including type of constituent, imagery, and message source, impact their reception among smokers. Specifically, communication campaigns targeting smokers that utilize arsenic as the tobacco constituent, visual imagery, and the FDA logo may be particularly effective in changing key outcomes that are associated with subsequent attitude and behavioral changes.

IMPLICATIONS

This article describes how components of communication campaigns about cigarette constituents are perceived. Multiple elements of a tobacco constituent message, including type of constituent, image, and message source may influence the reception of messages among current smokers. Communication campaigns targeting smokers that utilize arsenic as the tobacco constituent, visual imagery, and the FDA logo may be particularly effective in changing key outcomes among smokers. The effects of such campaigns should be examined, as well as the mechanisms through which such campaigns affect change.

Adolescents' and Young Adults' Aesthetics and Functionality Preferences for Online Tobacco Education

As cigarette use rates decline among adolescents and young adults, public health officials face new challenges with high use of non-cigarette tobacco products (NCTPs). Online tobacco education is a potential solution to discourage use, yet limited information is available for how online media should look and function. This study aims to fill this gap by conducting focus group interviews to identify adolescents and young adults' aesthetic and functionality preferences for online tobacco education (phase 1) followed by interviews to assess a NCTP education website developed (phase 2). We found preferences for use of font and colors to highlight tobacco information in organized designs. Interactive features (quizzes) motivated engagement, and participants desired responsive designs that function similarly across devices. Public health researchers and educators should apply aesthetic and functionality preferences to reduce NCTP use and help create a tobacco-free future for youth.

Connections between sources of health and beauty information and indoor tanning behavior among college women

Objective: This study tested how media, family, and peer sources of health and beauty information predict indoor tanning (IT) beliefs and behavior. Participants: 210 undergraduate women at a state university in the southeastern United States. Methods: Respondents completed a survey about sources of health and beauty information, IT beliefs, and IT behavior. Correlations and a path model were used to test associations between variables. Results: Friends were positively and family were negatively associated with positive outcome expectations, with mood enhancement beliefs positively predicting behavior. Reliance on news positively predicted appearance damage and immediate risk, which both predicted behavior. Reliance on social media was negatively associated with beliefs about immediate risks. Conclusion: Health and beauty information from social media and from friends may promote beliefs about tanning, while information from news or one's family may reduce risky beliefs. Prevention efforts could leverage information sources to shift tanning beliefs and behavior.

Does Perceived Message Effectiveness Predict the Actual Effectiveness of Tobacco Education Messages? A Systematic Review and Meta-Analysis

Target audience ratings of the likely impact of persuasive messages, known as perceived message effectiveness (PME), are commonly used in health communication campaigns. However, applications of PME rely on a critical assumption-that is, that PME is a valid indicator of the likely effectiveness of messages. To examine the evidence supporting this assumption, we conducted a systematic review and meta-analysis of longitudinal studies in the tobacco education campaigns literature. Six longitudinal studies examining the predictive validity of PME met inclusion criteria. Results indicated that PME ratings were significantly associated with the majority of outcomes studied. In fact, each of the six studies found PME to be associated with at least one outcome, and across the six studies, PME was associated with message recall, conversations about ads, beliefs about smoking and quitting smoking, quit intentions, and cessation behavior. Meta-analyses demonstrated that PME predicted quit intentions (r = .256, p < .001) and cessation behavior (r = .201, p < .001), revealing effects that were small to medium in magnitude. Our results suggest that PME provides some predictive value as to the likely effectiveness of messages, although additional work using different validation designs, with other health behaviors, and among other populations is needed.

Physical activity calorie expenditure (PACE) labels in worksite cafeterias: effects on physical activity

BACKGROUND

Regular physical activity is an important component of healthy living and wellbeing. Current guidelines recommend that adults participate in at least 150 min of moderate or vigorous-intensity physical activity weekly. In spite of the benefits, just over half of U.S. adults meet these recommendations. Calorie-only food labels at points of food purchase have had limited success in motivating people to change eating behaviors and increase physical activity. One new point of purchase approach to promote healthy behaviors is the addition of food labels that display the physical activity requirement needed to burn the calories in a food item (e.g. walk 15 min).

METHODS

The Physical Activity Calorie Expenditure (PACE) Study compared activity-based calorie-expenditure food labels with calorie-only labels at three Blue Cross and Blue Shield of North Carolina worksite cafeterias. After 1 year of baseline data collection, one cafeteria had food items labeled with PACE labels, two others had calorie-only food labels. Cohort participants were asked to wear an accelerometer and complete a self-report activity questionnaire on two occasions during the baseline year and twice during the intervention year.

RESULTS

A total of 366 study participants were included in the analysis. In the PACE-label group, self-reported physical activity increased by 13-26% compared to the calorie-only label group. Moderate-to-vigorous physical activity (MVPA) increased by 24 min per week in the PACE-label group compared to the calorie-label group (p = 0.06). Changes in accelerometer measured steps, sedentary time, and MVPA had modest increases. Change ranged from 1 to 12% with effect size values from 0.08 to 0.15. Baseline physical activity level significantly moderated the intervention effects for all physical activity outcomes. Participants in both label groups starting in the lowest tertile of activity saw the largest increase in their physical activity.

CONCLUSION

Results suggest small positive effects for the PACE labels on self-reported and objective physical activity measures. Minutes of weekly MVPA, strength training, and exercise activities showed modest increases. These results suggest that calorie-expenditure food labels may result in some limited increases in physical activity.

Public Knowledge and Credibility Perceptions of the FDA as a Tobacco Regulator

Introduction

Since the U.S. Food and Drug Administration (FDA) was granted regulatory authority over tobacco products in 2009, few studies have examined perceived credibility of the FDA in this role. The current study assessed knowledge and credibility of the FDA as a regulator of tobacco products.

Methods

In a nationally representative survey of U.S. adults (N = 4758), we assessed knowledge that the FDA regulates the manufacture, distribution, and marketing of cigarettes, and credibility of the FDA as a tobacco regulator. We examined demographic differences in knowledge and credibility, and associations of knowledge and trust in government with credibility perceptions.

Results

Less than half of respondents reported knowing the FDA regulates how cigarettes are sold (46.8%) and advertised (49.7%), and only 36.0% knew the FDA regulates how cigarettes are made, with few demographic differences. Respondents reported that the FDA was moderately credible in regulating tobacco. Knowledge of the FDA as a tobacco regulator and trust in government were the strongest predictors of credibility. Being of younger age, being White (compared to African American), and being male were associated with higher credibility ratings of the FDA.

Conclusions

Much of the public still does not know that the FDA regulates tobacco products, and credibility perceptions are moderate. Greater knowledge of the FDA's regulatory role was associated with higher credibility; efforts that increase the public's understanding of the FDA's role as a tobacco regulator may positively impact views of the agency's credibility. This may in turn improve public reception to the FDA's messages and regulations.

Implications

This study is the first to show nationally representative estimates of both knowledge and credibility of the FDA as a tobacco regulator. Our research shows further that knowledge of the FDA's tobacco regulatory roles is likely to be an important factor related to perceived credibility of the FDA. Increasing the public's knowledge of the FDA's roles may enhance the agency's credibility, which can improve public reception to messages and regulations.

Believability of Cigarette Warnings About Addiction: National Experiments of Adolescents and Adults

Introduction

We conducted two experiments to examine the believability of three addiction-focused cigarette warnings and the influence of message source on believability among adolescents and adults in the United States.

Methods

Experimental data were collected using national phone surveys of adolescents (age 13-17; n = 1125; response rate, 66%) and adults (age 18+; n = 5014; response rate, 42%). We assessed the believability of three cigarette warnings about addiction attributed to four message sources (Food and Drug Administration [FDA], Surgeon General, Centers for Disease Control and Prevention [CDC], no source).

Results

The majority of adolescents and adults reported the three cigarette warnings were very believable (49%-81% for adolescents; 47%-76% for adults). We found four to five times higher odds of adolescents believing a warning that cigarettes are addictive (warning 1) or that nicotine was an addictive chemical (warning 2) compared to a warning that differentiated the addictive risks of menthol versus traditional cigarettes (warning 3), warning 1 adjusted odds ratio (aOR): 4.53, 95% confidence interval (CI): 3.10, 6.63; warning 2 aOR: 3.87, 95% CI: 2.70, 5.50. Similarly, we found three to five times higher odds of adults (including current smokers) believing the same warnings, warning 1 aOR: 3.74, 95% CI: 2.82, 4.95; warning 2 aOR: 3.24, 95% CI: 2.45, 4.28. Message source had no overall impact on the believability of warnings for either population.

Conclusions

Our findings support the implementation of FDA's required warnings that cigarettes are addictive and that nicotine is an addictive chemical. These believable warnings may deter adolescents from initiating smoking and encourage adults to quit smoking.

Implications

This article describes, for the first time, the believability of different cigarette warnings about addiction. We now know that the majority of adolescents and adults believe cigarette warnings that highlight cigarettes as addictive and that nicotine is an addictive chemical in tobacco. However, a warning that highlighted the relative risk of addiction for menthol cigarettes compared to traditional cigarettes was not as believable among either population. Our findings support the implementation of FDA's required warnings that cigarettes are addictive and that nicotine is an addictive chemical that may deter adolescents from initiating smoking and encourage adults to quit smoking.

Impact of adding and removing warning label messages from cigarette packages on adult smokers' awareness about the health harms of smoking: findings from the ITC Canada Survey

INTRODUCTION

Adding messages to cigarette health warning labels (HWLs) about the harms of smoking increases awareness of these health facts, but little is known about the impact of removing messages. This is the first study to directly investigate the impact of adding and removing messages from cigarette HWLs on smokers' awareness of harms.

METHODS

Data were drawn from nine waves of the International Tobacco Control (ITC) Canada Survey, a national representative cohort of adult smokers (n=5863) conducted nearly annually between 2002 and 2013-2014. Two analytical approaches were conducted: generalised estimating equation (GEE) regression models estimated adjusted percentages of correct smoking-related health statements at each wave and segmented regression analyses modelled temporal trends in awareness before and after the revisions by measuring the difference in slopes.

RESULTS

Adding messages to HWLs significantly increased awareness that smoking causes blindness (OR=3.36 (95% CI 2.71 to 4.18); p<0.001; estimated increase of 1.01 million smokers in Canada) and bladder cancer (OR=2.14 (95% CI 1.71 to 2.66), p<0.001; estimated increase of 1.09 million smokers). Adding the warning that nicotine causes addiction did not significantly impact smokers' awareness. Removing messages was shown to decrease awareness that cigarette smoke contains carbon monoxide (OR=0.53 (95% CI 0.41 to 0.70), p<0.001; estimated decrease of 342 000 smokers) and smoking causes impotence (p=0.007 for the difference in slopes; estimated decrease of 354 000 smokers).

CONCLUSIONS

Adding messages to HWLs increases smokers' awareness of health facts, but removing messages decreases awareness. These findings demonstrate the importance of carefully considering the implications of adding and especially removing messages from HWLs and the importance of regularly revising warnings.

UNC Perceived Message Effectiveness: Validation of a Brief Scale

BACKGROUND

Interventionists commonly identify promising messages for health communication efforts based on audience members' ratings of perceived message effectiveness (PME).

PURPOSE

We sought to validate a new PME measure that improved on existing scales by focusing on the behavior and respondent, being brief, and having strong psychometric properties.

METHODS

Participants were a national convenience sample of 999 adults and national probability samples of 1,692 adults and 869 adolescents recruited in 2015. Smokers and nonsmokers rated up to six brief messages about the chemicals in cigarette smoke on two PME scales. The first was the new three-item University of North Carolina (UNC) PME Scale that assessed effects perceptions. The second was an established six-item PME scale that assessed message perceptions. We examined the UNC PME Scale's psychometric properties and compared both scales using item factor analysis.

RESULTS

The UNC PME Scale measured the same construct across multiple chemical messages (all factor loadings ≥ 0.86). It exhibited high reliability (>0.85) over very low to moderate levels of PME (z = -2.5 to 0.2), a range that is useful for identifying more promising messages. Samples of adults and adolescents showed a similar pattern of results. As expected, the UNC PME Scale was strongly positively correlated with message perceptions (r = .84). It also exhibited strong psychometric properties among participants regardless of education, reactance, sex, and smoking status.

DISCUSSION

The UNC PME Scale reliably and validly measured PME among adults and adolescents from diverse groups. This brief scale may be used to efficiently evaluate candidate antismoking messages and may be suitable for adaptation to other health risk behaviors.

Effects of E-cigarette Advertising Message Form and Cues on Cessation Intention: An Exploratory Study

A common message in e-cigarette advertising is that e-cigarettes can be used anywhere. E-cigarette advertisements often express this message implicitly (e.g., "Whenever, wherever") alongside images of e-cigarettes that physically resemble combustible cigarettes. These implicit messages and "cigalike" images may cross-cue combustible cigarette smoking cognitions and behavior. This exploratory study was a 2 (message form: implicit or explicit e-cigarette use anywhere message) by 2 (presence or absence of e-cigarette cue) experiment with U.S. adult smokers (n = 2,201). Participants were randomized to view e-cigarette advertisements that varied by study condition. Three combustible cigarette outcomes were investigated: smoking cessation intention, smoking urges, and immediate smoking behavior. Mediation analysis was also performed to investigate mechanisms of the message form effect through descriptive and normative beliefs about smoking. Compared to its explicit counterpart, the implicit e-cigarette use anywhere message evoked greater smoking urges. Participants exposed to the implicit message also perceived cigarette smoking to be more prevalent and, in turn, reported greater cessation intention. There was no evidence of e-cigarette cue or message form × cue interaction effects. Implicit e-cigarette use anywhere messages may create a predisposition towards smoking compared to their explicitly written counterparts, but whether this effect undermines cessation deserves further attention.

Impact of e-cigarette health warnings on motivation to vape and smoke

BACKGROUND

A prevailing hypothesis is that health warnings for electronic cigarettes (e-cigarettes) could drive people away from vaping and towards smoking cigarettes. We consider an alternative hypothesis that e-cigarette warnings discourage both vaping and smoking.

METHODS

Participants were a national convenience sample of 2218 US adults who used e-cigarettes, cigarettes or both. In August 2018, we randomised participants to one of three warning types (control text about littering, text-only e-cigarette warning or pictorial e-cigarette warning). We further randomised participants viewing e-cigarette warnings to one of three topics (nicotine addiction, health hazards of use, or both health hazards and harms of use). The preregistered primary outcome was intentions to quit vaping among e-cigarette users. Secondary outcomes included interest in smoking and Tobacco Warnings Model constructs: attention, negative affect, anticipated social interactions and cognitive elaboration.

RESULTS

Text warnings elicited higher intentions to quit vaping than control among e-cigarette users (d=0.44, p<0.001), and pictorial warnings elicited still higher intentions to quit vaping than text (d=0.12, p<0.05). Text warnings elicited lower interest in smoking compared with control among smokers (p<0.05); warnings had no other effects on interest in smoking among smokers or non-smokers. Text warnings about health hazards elicited higher intentions to quit vaping than nicotine addiction warnings. E-cigarette warnings also increased Tobacco Warnings Model constructs.

DISCUSSION

E-cigarette health warnings may motivate users to quit vaping and discourage smoking. The most promising warnings include health hazards (other than nicotine addiction) and imagery. We found no support for the hypothesis that e-cigarette warnings could encourage smoking cigarettes.

Impact of tobacco-pack pictorial warnings on youth and young adults: A systematic review of experimental studies

INTRODUCTION

We conducted a systematic review of the experimental literature on the impact of tobacco-pack pictorial warning labels (PWLs) on youth and young adults.

METHODS

We systematically searched computerized databases and the reference lists of relevant articles. We included studies that used an experimental protocol to assess PWLs. Studies had to report findings for youth or young adult samples (aged <30 years). Thirty-one studies met the inclusion criteria, with a total sample size of 27506. Two coders independently coded all study characteristics and outcomes.

RESULTS

Twenty-eight studies experimentally evaluated PWLs for cigarette packs while three studies evaluated PWLs for smokeless tobacco packs. Generally, PWLs led to higher attention, stronger cognitive and affective reactions, more negative pack attitudes and smoking attitudes, and increased intentions not to use tobacco products compared to text warnings. PWLs were perceived to be more effective than text warnings for both cigarette packs and smokeless tobacco packs.

CONCLUSIONS

The systematic review showed that PWLs on tobacco products are effective across a wide range of tobacco-related outcomes among young people. Gaps in the literature include a lack of research on tobacco initiation and cessation and a dearth of literature on non-cigarette tobacco products.

Adolescents' receptivity to E-cigarette harms messages delivered using text messaging

INTRODUCTION

E-cigarette use among adolescents has dramatically risen since 2011, yet little research has tested e-cigarette harms messages among adolescents. We conducted a pretest-posttest pilot study to examine adolescents' receptivity to e-cigarette health harms messages delivered using text messaging.

METHODS

N = 69 adolescents were enrolled in an 8-day pretest-posttest text messaging study. Participants completed a pretest survey on day one, were texted one of three e-cigarette health harms messages per day on days two through seven, and completed a posttest survey on day eight (88% retention). We assessed message ratings at posttest and knowledge, thoughts, and beliefs about e-cigarette harms at pretest and posttest.

RESULTS

Adolescents rated the three messages favorably, with both the chemical and brain messages scoring higher than the nicotine message on fear arousal and perceived message effectiveness. More than one-third of adolescents showed the messages to others and talked to others about the messages. At posttest, knowledge about the harms of e-cigarettes, thinking about the risks of e-cigarettes, and perceived risks of e-cigarettes were all significantly higher compared to pretest (p < .05). Participants largely adhered to the text messaging protocol and found the study highly acceptable.

CONCLUSIONS

This pilot study suggests that adolescents are receptive to e-cigarette health harms messages and that delivering such messages using text messaging is feasible and acceptable. Future research should systematically develop and test a broad set of e-cigarette health harms messages and examine their impact in a randomized controlled trial.

Developing a Point-of-Sale Health Communication Campaign for Cigarillos and Waterpipe Tobacco

Adolescents and young adults smoke waterpipe tobacco (WT) and cigarillos, at least in part, based on erroneous beliefs that these products are safer than cigarettes. To address this challenge, we used a systematic, three-phase process to develop a health communication campaign to discourage WT and cigarillo smoking among at-risk (tobacco users and susceptible non-users) 16- to 25-year-olds. In Phase 1, we used a national phone survey (N = 896) to determine salient message beliefs. Participants reported constituents (i.e., harmful chemicals) emitted by the products were worrisome. In Phase 2, we developed and evaluated four message executions, with varying imagery, tone, and unappealing products with the same constituents, using focus groups (N = 38). Participants rated one execution highly, resulting in our development of a campaign where each message: (1) identified a tobacco product and constituent in the smoke; (2) included an image of an unappealing product containing the constituent (e.g., pesticides, gasoline) to grab attention; and (3) used a humorous sarcastic tone. In Phase 3, we tested the campaign messages (17 intervention and six control) with a nationally representative online survey (N = 1,636). Participants rated intervention and control messages highly with few differences between them. Exposure to messages resulted in significant increases in all risk beliefs from pre to post (p < 0.05). For WT, intervention messages increased beliefs about addiction more than control messages (p < 0.05). This systematic, iterative approach resulted in messages that show promise for discouraging WT and cigarillo use.

Systematic Review of Health Communication for Non-Cigarette Tobacco Products

The Food and Drug Administration, which now has regulatory authority over all tobacco products meeting the statutory definition, is tasked with communicating the risks of these products to the public through health warnings and public education. However, there have been no attempts to summarize what is known about non-cigarette tobacco product (NCTP) health messaging. We conducted a systematic review to examine the existing literature on health communication for NCTPs and identify key research gaps. A total of 45 unique studies were retrieved and coded, with the majority focused on messaging for smokeless tobacco (SLT, k = 32, 71.1%), followed by waterpipe tobacco (WT, k = 9, 20%), electronic nicotine delivery systems (ENDS, k = 2, 4.4%), cigars (k = 2, 4.4%), and a potentially reduced exposure product (k = 1, 2.2%). Studies most commonly examined tobacco product warnings (k = 26, 57.8%) and public education (k = 19, 42.2%), which included mass media campaigns. Most studies examined knowledge, attitudes, and beliefs as outcomes (k = 27, 60%), while behavior was an outcome in the minority of studies (k = 8, 17.8%). Pictorial warnings and public education about NCTPs demonstrated positive impact in some studies, although the literature is nascent. Given the increasing use of NCTPs such as ENDS, WT, and cigars, particularly among adolescents and young adults, more research is needed on effective ways to communicate product risk to those audiences most at risk.

Communication Regulatory Science: Mapping a New Field

Communication regulatory science is an emerging field that uses validated techniques, tools, and models to inform regulatory actions that promote optimal communication outcomes and benefit the public. In the opening article to this special issue on communication and tobacco regulatory science, we 1) describe Food and Drug Administration (FDA) regulation of tobacco products in the US; 2) introduce communication regulatory science and provide examples in the tobacco regulatory science realm; and 3) describe the special issue process and final set of articles. Communication research on tobacco regulatory science is a burgeoning area of inquiry, and this work advances communication science, informs and potentially guides the FDA, and may help to withstand legal challenges brought by the tobacco industry. This research has the potential to have a major impact on the tobacco epidemic and population health by helping implement the most effective communications to prevent tobacco initiation and increase cessation. This special issue provides an example of 10 studies that exemplify tobacco regulatory science and demonstrate how the health communication field can affect regulation and benefit public health.

A Secondary Audience's Reactions to "The Real Cost" Advertisements: Results From a Study of U.S. Young Adult Smokers and Susceptible Nonsmokers

INTRODUCTION

Exposure to "The Real Cost" campaign has prevented smoking initiation among its target audience (U.S. youth aged 12-17 years). This study examines reactions to "The Real Cost" advertisements among a potential secondary audience: U.S. young adults.

METHODS

An online convenience sample of young adult (ages 18-29 years) smokers (n=225) and susceptible nonsmokers (n=339) participated in a within-subjects experiment in 2017. Participants viewed three TV ads from "The Real Cost" campaign and reported their past exposure to, conversations about, and reactions to the ads. In 2017, analyses examined message-level and person-level predictors of perceived message effectiveness using multilevel modeling.

RESULTS

About half of smokers (47%) and susceptible nonsmokers (51%) had seen at least one of the three ads in the past 3 months. About one in four smokers (23%) and susceptible nonsmokers (24%) had at least one conversation about the ads in the past 3 months. Susceptible nonsmokers rated the ads higher on perceived message effectiveness than smokers (p<0.01), but lower on message relevance and negative affective reactions to the ads (both p<0.05). In both samples, ads that elicited higher negative affective reactions and message relevance, and lower message reactance (i.e., resistance) received higher perceived message effectiveness ratings (all p<0.05).

CONCLUSIONS

"The Real Cost" ads have reached and generated conversations among a convenience sample of young adult smokers and susceptible nonsmokers. Increasing the perceived relevance and emotional reactions of campaigns may increase their impact. Future studies should examine reactions to "The Real Cost" campaign and effects on smoking behavior using nationally representative samples of young adults.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Effect of calories-only vs physical activity calorie expenditure labeling on lunch calories purchased in worksite cafeterias

BACKGROUND

Calorie labeling on restaurant menus is a public health strategy to guide consumer ordering behaviors, but effects on calories purchased have been minimal. Displaying labels communicating the physical activity required to burn calories may be a more effective approach, but real-world comparisons are needed.

METHODS

In a quasi-experimental study, we examined the effect of physical activity calorie expenditure (PACE) food labels compared to calorie-only labels on point-of-decision food purchasing in three worksite cafeterias in North Carolina. After a year of quarterly baseline data collection, one cafeteria prominently displayed PACE labels, and two cafeterias prominently displayed calorie-only labels. Calories from foods purchased in the cafeteria during lunch were assessed over 2 weeks every 3 months for 2 years by photographs of meals. We compared differences in purchased calorie estimates before and after the labeling intervention was introduced using longitudinal generalized linear mixed model regressions that included a random intercept for each participant.

RESULTS

In unadjusted models comparing average meal calories after vs before labeling, participants exposed to PACE labels purchased 40.4 fewer calories (P = 0.002), and participants exposed to calorie-only labels purchased 38.2 fewer calories (P = 0.0002). The small difference of 2 fewer calories purchased among participants exposed to PACE labeling vs calorie-only labeling was not significant (P = 0.90). Models adjusting for age, sex, race, occupation, numeracy level, and health literacy level did not change estimates appreciably.

CONCLUSION

In this workplace cafeteria setting, PACE labeling was no more effective than calorie-only labeling in reducing lunchtime calories purchased.

E-Cigarette Outcome Expectancies among Nationally Representative Samples of Adolescents and Young Adults

Objectives: We conducted nationally representative surveys of adolescents and young adults to examine associations between e-cigarette outcome expectancies and e-cigarette use. Background: E-cigarette use among adolescents and young adults has grown rapidly in recent years, yet little research has examined the beliefs that may underlie this behavior among nationally representative samples. Methods:N = 1,298 adolescents (13-17) and 2,219 young adults (18-25) were surveyed using a probability-based web panel. Participants completed a survey that included a new outcome expectancy measure examining 3 positive (enjoyment, social influences, advantage over cigarettes) and 2 negative (health concerns, smoker association) expectancy domains and ever having used e-cigarettes [ever use]. Results: Confirmatory factor analyses demonstrated a good fit of the outcome expectancies' factor structure to the data. All outcome expectancies were associated with e-cigarette use in both populations in univariate analyses. In multiple logistic regression models controlling for several covariates, higher expected enjoyment was positively associated with a greater likelihood of e-cigarette use (aOR = 2.10, p < .05) among adolescents. Among young adults, enjoyment (aOR = 3.08, p < .001) was positively associated with a greater likelihood of use while both health concerns (aOR = 0.70, p < .01) and smoker association (aOR = 0.73, p < .05) were negatively associated with e-cigarette use. Conclusions: This study suggests that expected enjoyment is robustly associated with e-cigarette use among both adolescents and young adults. Health concerns may also play a role in e-cigarette use. Implications for e-cigarette prevention efforts and future research directions are discussed.