Misinformation and other elements in HPV vaccine tweets: an experimental comparison

Our study examined how misinformation and other elements of social media messages affect antecedents to human papillomavirus (HPV) vaccination of adolescents. In 2017-2018, we randomly assigned a national sample of 1206 U.S. parents of adolescents to view one tweet using a 2 × 2 × 2 × 2 between-subjects factorial experiment. The 16 experimental tweets varied four messaging elements: misinformation (misinformation or not), source (person or organization), narrative style (storytelling or scientific data), and topic (effectiveness or safety). Parents reported their motivation to vaccinate (primary outcome), trust in social media content, and perceived risk about HPV-related diseases. Tweets without misinformation elicited higher HPV vaccine motivation than tweets with misinformation (25% vs. 5%, OR = 6.60, 95% CI:4.05, 10.75). Motivation was higher for tweets from organizations versus persons (20% vs. 10%, OR = 2.47, 95% CI:1.52, 4.03) and about effectiveness versus safety (20% vs. 10%, OR = 2.03, 95% CI:1.24, 3.30). Tweets with misinformation produced lower trust and higher perceived risk (both p < .01), with impact varying depending on source and topic. In conclusion, misinformation was the most potent social media messaging element. It may undermine progress in HPV vaccination.

Talking about recommended age or fewer doses: what motivates HPV vaccination timeliness?

HPV vaccination is recommended for U.S. adolescents at ages 11-12 and requires two versus three doses if the series is started before age 15. We evaluated how talking about recommended age or fewer doses motivates on-time HPV vaccination. Our national, online experiment randomized 1,263 parents of adolescents to view one of three messages about HPV vaccination recommendations or no message. Messages framed guidelines as recommending: vaccination at age 11-12; fewer doses for those who start vaccination at age 11-12; or, fewer doses for those who start vaccination before age 15. We then assessed parents' preferred age for HPV vaccination, categorizing preferences of ≤12 years as on-time. Parents who viewed "at age 11-12" versus no message more often preferred on-time HPV vaccination (63% vs. 43%, p < .05) and did not differ from those viewing "fewer doses at age 11-12" (63% vs. 64%, p > .05). Parents who viewed "fewer doses before age 15" less often preferred on-time HPV vaccination (39%, p < .05). Recommending HPV vaccination at age 11-12 encouraged on-time vaccination, while offering fewer doses had little impact. Providers should avoid framing HPV vaccination guidelines in reference to age 15 because doing so may discourage on-time vaccination by introducing confusion about the recommended age.

What Works to Increase Vaccination Uptake

Behavioral science offers several ideas about what it takes to get people to vaccinate. Colleagues and I previously reviewed the evidence for these propositions and put forward what has become known as the Increasing Vaccination Model. To make the model more accessible to practitioners, the current paper summarizes the main insights from the earlier work. First, observational studies show clearly that thoughts and feelings are correlated with vaccine uptake. Such constructs include perceived risk of harm from infectious disease and confidence in vaccine safety and efficacy. However, interventions have not generally shown that changing thoughts and feelings increases vaccine uptake. Second, social processes are promising in observational studies. Such constructs include social norms, altruism, and sharing through social media. More research is needed in this promising area before it will be possible to conclude whether social processes are effective intervention targets. Third, interventions that directly change behavior-without trying to change what people think or feel or their social experience-are reliably effective ways to increase vaccine uptake. Such interventions include reminders, defaults, and vaccine requirements. Finally, the most potent intervention for increasing vaccine uptake is a health care provider recommendation, but it is still unclear whether such recommendations are effective because they increase confidence, set a social norm, or reflect a direct behavior change technique. The paper ends by describing use of the model by a World Health Organization working group as it considers opportunities to address low vaccination uptake globally.

Perceived Financial Barriers to Cervical Cancer Screening and Associated Cost Burden Among Low-Income, Under-Screened Women

Background: Despite screening's effectiveness in reducing cervical cancer incidence and mortality, disparities in cervical cancer screening uptake remain, with lower rates documented among uninsured and low-income individuals. We examined perceived financial barriers to, and the perceived cost burden of, cervical cancer screening. Materials and Methods: We surveyed 702 low-income, uninsured or publicly insured women ages 25-64 years in North Carolina, U.S., who were not up to date on cervical cancer screening according to national guidelines. Participants were asked about perceived financial barriers to screening and how much they perceived screening would cost. We used multivariable logistic regression to assess the sociodemographic predictors of perceived financial barriers. Results: Seventy-two percent of participants perceived financial barriers to screening. Screening appointment costs (71%) and follow-up/future treatment costs (44%) were most commonly reported, followed by lost pay due to time missed from work (6%) and transportation costs (5%). In multivariable analysis, being uninsured (vs. publicly insured), younger (25-34 vs. 50-64 years), White (vs. Black), and not reporting income data were associated with perceiving screening costs and future treatment costs as barriers to screening. Participants reported wide-ranging estimates of the perceived out-of-pocket cost of screening ($0-$1300), with a median expected cost of $245. Conclusions: The majority of our sample of low-income women perceived substantial financial barriers to screening, particularly related to screening appointment costs and potential follow-up/future treatment costs. Providing greater cost transparency and access to financial assistance may reduce perceived financial barriers to screening, potentially increasing screening uptake among this underserved population. Clinicaltrials.gov registration number NCT02651883.

Predictors of willingness to get a COVID-19 vaccine in the U.S

BACKGROUND

As COVID-19 vaccine distribution efforts continue, public health workers can strategize about vaccine promotion in an effort to increase willingness among those who may be hesitant.

METHODS

In April 2020, we surveyed a national probability sample of 2279 U.S. adults using an online panel recruited through address-based sampling. Households received a computer and internet access if needed to participate in the panel. Participants were invited via e-mail and answered online survey questions about their willingness to get a novel coronavirus vaccine when one became available. The survey was completed in English and Spanish. We report weighted percentages.

RESULTS

Most respondents were willing to get the vaccine for themselves (75%) or their children (73%). Notably, Black respondents were less willing than White respondents (47% vs. 79%, p < 0.001), while Hispanic respondents were more willing than White respondents (80% vs. 75%, p < 0.003). Females were less likely than makes (72% vs. 79%, p < 0.001). Those without insurance were less willing than the insured (47% vs. 78%, p < 0.001). Willingness to vaccinate was higher for those age 65 and older than for some younger age groups (85% for those 65 and older vs. 75% for those 50-64, p < 0.017; 72% for those 35-49, p < 0.002; 70% for those 25-34, p = NS and 75% for ages 18-24, p = NS), but other groups at increased risk because of underlying medical conditions or morbid obesity were not more willing to get vaccinated than their lower risk counterparts.

CONCLUSIONS

Most Americans were willing to get a COVID-19 vaccine, but several vulnerable populations reported low willingness. Public health efforts should address these gaps as national implementation efforts continue.

Implementation of QI Coaching Versus Physician Communication Training for Improving HPV Vaccination in Primary Care: A Randomized Implementation Trial

Purpose of study: Health departments (HDs) are at the forefront of efforts to improve HPV vaccine uptake in the US. Most notably, HD staff routinely conduct in-person quality improvement (QI) coaching to help primary care clinics improve their vaccine delivery systems. Some HDs also engage outside experts to conduct remote physician communication training to help vaccine prescribers recommend HPV vaccine more effectively. To guide future HD programming, we sought to understand the implementation strengths and challenges of QI coaching and physician communication training. Methods: In a cluster randomized trial, we allocated 855 primary care clinics in 3 geographically-diverse US states to receive: 1) QI coaching; 2) physician communication training; or 3) both interventions combined. In each arm, we assessed adoption (or the % of clinics receiving the allocated intervention out of those invited), contacts per clinic (mean number of contacts needed to successfully schedule one clinic), reach (median number of total staff and prescriber participants per clinic), and delivery cost. Results: More clinics adopted QI coaching than communication training or the combined intervention (63% vs 16% and 12%, both p&lt;.05). Recruiting clinics into QI coaching sessions required fewer contacts than communication training or the combined intervention (mean = 4.7 vs 29.0 and 40.4, both p&lt;.05). In contrast, communication training and the combined intervention reached more total staff per clinic than QI coaching (median = 5 and 5 vs 2, both p&lt;.05), including more prescribers per clinic (2 and 2 vs 0, both p&lt;.05). QI coaching cost $439 per clinic on average, including costs incurred from follow up ($129/clinic), session preparation ($73/clinic), and travel ($69/clinic). Communication training cost $1,287 per clinic, with most cost incurred from clinic recruitment ($653/clinic). Conclusions: QI coaching was lower cost and had higher adoption, but remote communication training achieved higher reach, including to highly influential vaccine prescribers. Thus, communication training is a promising intervention for improving HPV vaccine delivery, although care will be needed to overcome substantial challenges to clinic recruitment.

Measuring Cigarette Smoking Risk Perceptions

Risk perception is an important construct in many health behavior theories. Smoking risk perceptions are thoughts and feelings about the harms associated with cigarette smoking. Wide variation in the terminology, definition, and assessment of this construct makes it difficult to draw conclusions about the associations of risk perceptions with smoking behaviors. To understand optimal methods of assessing adults' cigarette smoking risk perceptions (among both smokers and nonsmokers), we reviewed best practices from the tobacco control literature, and where gaps were identified, we looked more broadly to the research on risk perceptions in other health domains. Based on this review, we suggest assessments of risk perceptions (1) about multiple smoking-related health harms, (2) about harms over a specific timeframe, and (3) for the person affected by the harm. For the measurement of perceived likelihood in particular (ie, the perceived chance of harm from smoking based largely on deliberative thought), we suggest including (4) unconditional and conditional items (stipulating smoking behavior) and (5) absolute and comparative items and including (6) comparisons to specific populations through (7) direct and indirect assessments. We also suggest including (8) experiential (ostensibly automatic, somatic perceptions of vulnerability to a harm) and affective (emotional reactions to a potential harm) risk perception items. We also offer suggestions for (9) response options and (10) the assessment of risk perception at multiple time points. Researchers can use this resource to inform the selection, use, and future development of smoking risk perception measures.

IMPLICATIONS

Incorporating the measurement suggestions for cigarette smoking risk perceptions that are presented will help researchers select items most appropriate for their research questions and will contribute to greater consistency in the assessment of smoking risk perceptions among adults.

Cost-effectiveness of Interventions to Increase HPV Vaccine Uptake

OBJECTIVES

We sought to prioritize interventions for increasing human papillomavirus (HPV) vaccination coverage based on cost-effectiveness from a US state perspective to inform decisions by policy makers.

METHODS

We developed a dynamic simulation model of HPV transmission and progression scaled to a medium-sized US state (5 million individuals). We modeled outcomes over 50 years comparing no intervention to a one-year implementation of centralized reminder and recall for HPV vaccination, school-located HPV vaccination, or quality improvement (QI) visits to primary care clinics. We used probabilistic sensitivity analysis to assess a range of plausible outcomes associated with each intervention. Cost-effectiveness was evaluated relative to a conservative willingness-to-pay threshold; $50 000 per quality-adjusted life-year (QALY) .

RESULTS

All interventions were cost-effective, relative to no intervention. QI visits had the lowest cost and cost per QALY gained ($1538 versus no intervention). Statewide implementation of centralized reminder and recall cost $28 289 per QALY gained versus QI visits. School-located vaccination had the highest cost but was cost-effective at $18 337 per QALY gained versus QI visits. Scaling to the US population, interventions could avert 3000 to 14 000 future HPV cancers. When varying intervention cost and impact over feasible ranges, interventions were typically preferred to no intervention, but cost-effectiveness varied between intervention strategies.

CONCLUSIONS

Three interventions for increasing HPV vaccine coverage were cost-effective and offered substantial health benefits. Policy makers seeking to increase HPV vaccination should, at minimum, dedicate additional funding for QI visits, which are consistently effective at low cost and may additionally consider more resource-intensive interventions (reminder and recall or school-located vaccination).

Reactions to messages about smoking, vaping and COVID-19: two national experiments

Introduction

The pace and scale of the COVID-19 pandemic, coupled with ongoing efforts by health agencies to communicate harms, have created a pressing need for data to inform messaging about smoking, vaping, and COVID-19. We examined reactions to COVID-19 and traditional health harms messages discouraging smoking and vaping.

Methods

Participants were a national convenience sample of 810 US adults recruited online in May 2020. All participated in a smoking message experiment and a vaping message experiment, presented in a random order. In each experiment, participants viewed one message formatted as a Twitter post. The experiments adopted a 3 (traditional health harms of smoking or vaping: three harms, one harm, absent) × 2 (COVID-19 harms: one harm, absent) between-subjects design. Outcomes included perceived message effectiveness (primary) and constructs from the Tobacco Warnings Model (secondary: attention, negative affect, cognitive elaboration, social interactions).

Results

Smoking messages with traditional or COVID-19 harms elicited higher perceived effectiveness for discouraging smoking than control messages without these harms (all p <0.001). However, including both traditional and COVID-19 harms in smoking messages had no benefit beyond including either alone. Smoking messages affected Tobacco Warnings Model constructs and did not elicit more reactance than control messages. Smoking messages also elicited higher perceived effectiveness for discouraging vaping. Including traditional harms in messages about vaping elicited higher perceived effectiveness for discouraging vaping (p <0.05), but including COVID-19 harms did not.

Conclusions

Messages linking smoking with COVID-19 may hold promise for discouraging smoking and may have the added benefit of also discouraging vaping.

Public Understanding of Cigarette Smoke Chemicals: Longitudinal Study of US Adults and Adolescents

INTRODUCTION

The US Food and Drug Administration has increased communication efforts that aim to raise public awareness of the harmful constituents (ie, chemicals) in cigarette smoke. We sought to investigate whether the public's awareness of these chemicals has increased in light of such efforts.

METHODS

Participants were national probability samples of 11 322 US adults and adolescents recruited in 2014-2015 (wave 1) and 2016-2017 (wave 2). Cross-sectional telephone surveys assessed awareness of 24 cigarette smoke chemicals at both timepoints.

RESULTS

The proportion of US adults aware of cigarette smoke chemicals did not differ between waves 1 and 2 (25% and 26%, p = .19). In contrast, awareness of chemicals among adolescents fell from 28% to 22% (p < .001), mostly due to lower awareness of carbon monoxide, arsenic, benzene, and four other chemicals. Belief that most of the harmful chemicals in cigarette smoke come from burning the cigarette also fell from waves 1 to 2 (adults: 31% vs. 26%; adolescents: 47% vs. 41%, both ps < .05). Participants were more likely to be aware of cigarette smoke chemicals if they had been exposed to anti-smoking campaign advertisements (p < .05) or had previously sought chemical information (p < .05). Cigarette smoke chemical awareness did not differ between smokers and nonsmokers.

CONCLUSION

Awareness of cigarette smoke chemicals remains low and unchanged among adults and decreased somewhat among adolescents. The association of chemical awareness with information exposure via campaigns and information seeking behavior is promising. More concerted communication efforts may be needed to increase public awareness of cigarette smoke chemicals, which could potentially discourage smoking.

IMPLICATIONS

Awareness of the toxic chemicals in cigarette smoke may contribute to quitting. The US Food and Drug Administration is making efforts to increase public awareness of these chemicals. Two national surveys (2014-2017) found that chemical awareness was low among adults and adolescents. Although awareness did not change among adults, awareness among adolescents dropped over time. In addition, exposure to anti-smoking campaigns and chemical information seeking behavior were associated with higher awareness of chemicals in cigarette smoke. Campaigns and other efforts may be needed to increase awareness of cigarette smoke chemicals.

Physicians' rhetorical strategies for motivating HPV vaccination

RATIONALE

Receiving a healthcare provider's recommendation is a well-documented predictor of human papillomavirus (HPV) vaccination, and yet recommendations remain understudied and undertheorized.

OBJECTIVE

To qualitatively describe strategies providers use to motivate HPV vaccination.

METHOD

We surveyed a national sample of 771 U.S. primary care physicians. Data came from an open-ended item that assessed physicians' perspectives on the most effective thing they could say to persuade parents to get HPV vaccine for their 11- to 12-year-old children. Using a standardized codebook and two independent coders, we conducted a thematic analysis to identify rhetorical strategies underlying physicians' responses.

RESULTS

We identified two sets of strategies for motivating HPV vaccination. One set drew parents' attention to specific actors or vaccine characteristics. Physicians using these strategies asked parents to consider their children's individual risk in the short-term, named specific diseases that could be prevented, emphasized the novelty of HPV vaccine as a cancer prevention tool, and gave their personal endorsement for HPV vaccination. In contrast, the second set of strategies was more distancing and impersonal. Physicians using these strategies referenced future risk, described cancer prevention in general terms, framed HPV vaccine as similar to other vaccines, and shared organizational endorsements for HPV vaccination. Across these two sets of strategies, a tension emerged between the goals of engaging parents' perceptions of HPV as a threat to their children versus framing HPV vaccination as a normative standard of care.

CONCLUSIONS

Our findings suggest that theoretical frameworks, such as Construal Level Theory, may be helpful for positioning provider recommendations in the broader literature on persuasive communication. By identifying competing approaches to motivating HPV vaccination, this study lays the groundwork for future research to test the acceptability and impact of strategies for recommending routine preventive care.

Quality Improvement Coaching for Human Papillomavirus Vaccination Coverage: A Process Evaluation in 3 States, 2018-2019

Purpose and Objectives

Quality improvement (QI) coaching improves human papillomavirus (HPV) vaccination coverage, but effects of coaching have been small, and little is known about how and when QI coaching works. To assess implementation outcomes and explore factors that might explain variation in outcomes, we conducted a process evaluation of a QI coaching intervention for HPV vaccination.

Intervention Approach

QI coaches received tools and training to support 4 core coaching competencies: 1) expertise in using clinic-level adolescent vaccination data to drive change, 2) knowledge of the evidence base to support change in HPV vaccination practice, 3) familiarity with improvement strategies and action planning, and 4) skill in building relationships.

Evaluation Methods

Our mixed methods evaluation involved collecting quantitative data through effort-tracking logs and gathering qualitative data through in-depth interviews with QI coaches (N = 11) who worked with 89 clinics in 3 US states. Data were collected on implementation outcomes and on contextual factors that might explain variations in those outcomes. Implementation outcomes included adoption by clinics, reach to providers and staff (ie, participation in the coaching visit), and implementation fidelity.

Results

States achieved either high adoption or high reach, but not both. For example, state A had high adoption with 94% of clinics accepting a coaching visit, but low reach with a median of 1 participant per clinic. In contrast, state C had lower adoption (29%, P < .01) than state A but higher reach (median of 4 participants per clinic, P < .01). Generally, states had high coaching protocol fidelity with the exception of advising on strategies and action planning. QI coaches described factors that might explain these variations, including strength of relationships with clinic staff and whether they recruited clinics directly or through large clinic networks.

Implications for Public Health

Our findings have implications for the design of future QI coaching initiatives, including how coaches recruit clinics to ensure full clinic engagement, refinements to coaching visits, and how QI coaches can effectively engage with clinic networks. Findings could inform future QI coaching interventions to strengthen their impact on public health.

Evaluating the actual and perceived effectiveness of E-cigarette prevention advertisements among adolescents

BACKGROUND

The efficacy of e-cigarette prevention ads among adolescents has seldom been studied. We examined the impact of ads from the The Real Cost vaping prevention media campaign on what adolescents think and believe about vaping. We also sought to test whether perceived message effectiveness (PME) served as a proxy for ad impact.

METHODS

Participants were 543 U.S. adolescents ages 13-17. In an online experiment, we randomized participants to either: 1) persuasive e-cigarette prevention video ads from the Food and Drug Administration's The Real Cost campaign that was targeted to adolescents or 2) information-only e-cigarette harms control videos (control condition). Participants in each condition viewed 2 videos in a random order. After ad exposure, the survey assessed PME (message and effects perceptions), risk beliefs about vaping, attitudes toward vaping, and intentions to vape.

RESULTS

The FDA's The Real Cost ads led to higher beliefs about the harms of vaping (p < .001), more negative attitudes toward vaping (p < .001), and lower intentions to vape (p < .05) compared to the control videos. The Real Cost ads also scored higher on both message perceptions (p < .001) and effects perceptions (p < .001) compared to control videos. Effects perceptions were associated with all three outcomes (all ps < 0.001, adjusting for both types of PME and covariates), but message perceptions did not offer additional predictive value.

CONCLUSIONS

Exposure to The Real Cost vaping prevention ads gave adolescents a more negative view of vaping and lowered their intentions to vape compared to control videos. Effects perceptions may be superior to message perceptions as a proxy for e-cigarette prevention ad impact.

The Prototypes of Tobacco Users Scale (POTUS) for Cigarette Smoking and E-Cigarette Use: Development and Validation

Endorsing prototypes of cigarette smokers predicts cigarette smoking, but less is known about prototypes of users of other tobacco products. Our study sought to establish the reliability and validity of a measure of prototypes of smokers and e-cigarette users. Participants were from a national survey of smokers and non-smokers (n = 1414), a randomized clinical trial (RCT) of adult smokers (n = 2149), and adolescent children of adults in the trial (n = 112). The Prototypes of Tobacco Users Scale (POTUS) has four positive adjectives (cool, sexy, smart, and healthy) and four negative adjectives (disgusting, unattractive, immature, and inconsiderate) describing cigarette smokers and e-cigarette users. Confirmatory factor analyses identified a two-factor solution. The POTUS demonstrated strong internal consistency reliability in all three samples (median α = 0.85) and good test-retest reliability among adults in the RCT (median r = 0.61, 1-4 weeks follow-up). In the RCT, smokers more often agreed with negative prototypes for smokers than for e-cigarette users (mean = 2.03 vs. 1.67, p < 0.05); negative prototypes at baseline were also associated with more forgoing of cigarettes and making a quit attempt at the end of the trial (Week 4 follow-up). The POTUS may be useful to public health researchers seeking to design interventions that reduce tobacco initiation or cessation through the manipulation of tobacco user prototypes.

Overcoming barriers to adolescent vaccination: perspectives from vaccine providers in North Carolina

To capture strategies for achieving high adolescent coverage of tetanus-diphtheria-acellular pertussis (Tdap), meningococcal conjugate (MenACWY), and human papillomavirus (HPV) vaccination, we surveyed employees of 20 North Carolina (N.C.) clinics that achieved adolescent vaccination coverage higher than the state average. One employee per clinic completed a surveysummarizing clinic practices regarding adolescent vaccination; perceived barriers and facilitators to Tdap/MenACWY/HPV vaccination; and the role of "champions" who made special efforts to promote adolescent vaccination. Common perceived barriers for all vaccinations were parental opposition and logistical barriers to receiving vaccination. For HPV vaccination, employees cited parental concerns about sexual behavior and injection site pain; no school vaccination requirement; and low-perceived benefit in boys. Most clinics (80%) implemented successful changes to increase adolescent vaccination: consistently offering vaccination, tracking vaccination status using existing data, providing appointment reminders, updating providers on vaccination recommendations, and expanding vaccination hours. Strategies to improve HPV vaccination included co-administration with Tdap and MenACWY, and providing reminders to complete the vaccination series. Vaccine champions strongly recommended vaccination to parents (55%) and educated parents on vaccination recommendations (36%). Clinics in N.C.and similar settings can implement these and other low-resource strategies to overcome adolescent vaccination barriers.

ABBREVIATIONS

CDC=Centers for Disease Control and Prevention; EHR=Electronic health record; HPV=Human papillomavirus; Tdap=Tetanus-diphtheria-acellular pertussis vaccine; MenACWY=Meningococcal Conjugate Vaccine; NCIB=North Carolina Immunization Branch; NCIR=North Carolina Immunization Registry; ACIP=Advisory Committee on Immunization Practices.

Similarities and Differences in Tobacco Control Research Findings From Convenience and Probability Samples

BACKGROUND

Online convenience samples are a quick and low-cost way to study health behavior, but the comparability to findings from probability samples is not yet well understood.

PURPOSE

We sought to compare convenience and probability samples' findings for experiments, correlates, and prevalence in the context of tobacco control research.

METHODS

Participants were a probability sample of 5,014 U.S. adults recruited by phone from September 2014 through May 2015 (cost ~U.S.$620,000) and an online convenience sample of 4,137 U.S. adults recruited through Amazon Mechanical Turk (MTurk) in December 2014 (cost ~U.S.$17,000). Participants completed a survey with experiments, measures of tobacco product use and demographic characteristics.

RESULTS

MTurk convenience and probability samples showed the same pattern of statistical significance and direction in almost all experiments (21 of 24 analyses did not differ) and observational studies (19 of 25 associations did not differ). Demographic characteristics of the samples differed substantially (1 of 17 estimates did not differ), with the convenience sample being younger, having more years of education, and including more Whites and Asians. Tobacco product use also differed substantially (1 of 22 prevalence estimates did not differ), with the convenience sample reporting more cigarette and e-cigarette use (median error 19%).

CONCLUSIONS

Using MTurk convenience samples can yield generalizable findings for experiments and observational studies. Prevalence estimates from MTurk convenience samples are likely to be over- or underestimates.

Pictorial Cigarette Pack Warnings Increase Some Risk Appraisals But Not Risk Beliefs: A Meta-Analysis

Pictorial warnings on cigarette packs motivate smokers to quit, and yet the warnings' theoretical mechanisms are not clearly understood. To clarify the role that risk appraisals play in pictorial warnings' impacts, we conducted a meta-analysis of the experimental literature. We meta-analyzed 57 studies, conducted in 13 countries, with a cumulative N of 42,854. Pictorial warnings elicited greater cognitive elaboration (e.g., thinking about the risks of smoking; d = 1.27; p < .001) than text-only warnings. Pictorial warnings also elicited more fear and other negative affect (d = .60; p < .001). In contrast, pictorial warnings had no impact on perceived likelihood of harm (d = .03; p = .064), perceived severity (d = .16; p = .244), or experiential risk (d = .06; p = .449). Thus, while pictorial warnings increase affective and some cognitive risk appraisals, they do not increase beliefs about disease risk. We discuss the role of negative affect in warning effectiveness and the implications for image selection and warning implementation.

Ten considerations for effectively managing the COVID-19 transition

Governments around the world have implemented measures to manage the transmission of coronavirus disease 2019 (COVID-19). While the majority of these measures are proving effective, they have a high social and economic cost, and response strategies are being adjusted. The World Health Organization (WHO) recommends that communities should have a voice, be informed and engaged, and participate in this transition phase. We propose ten considerations to support this principle: (1) implement a phased approach to a 'new normal'; (2) balance individual rights with the social good; (3) prioritise people at highest risk of negative consequences; (4) provide special support for healthcare workers and care staff; (5) build, strengthen and maintain trust; (6) enlist existing social norms and foster healthy new norms; (7) increase resilience and self-efficacy; (8) use clear and positive language; (9) anticipate and manage misinformation; and (10) engage with media outlets. The transition phase should also be informed by real-time data according to which governmental responses should be updated.

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.

Abstract B122: Racial and ethnic disparities and reverse disparities in HPV vaccination: A meta-analysis

Importance: Studies disagree about whether human papillomavirus (HPV) vaccination uptake differs meaningfully among racial and ethnic groups, an important issue given large disparities in some HPV-associated cancers.

Objective: To comprehensively characterize racial and ethnic differences in HPV vaccine initiation and follow-through.

Data Sources: We systematically searched PubMed, CINAHL, Embase, and Web of Science to identify US studies from 2006 through mid-2017 reporting the association of race and ethnicity with HPV vaccination. We identified 118 studies (n=3,095,486) that met inclusion criteria.

Study Selection: Included studies were published in English and reported HPV vaccine initiation or follow-through in the US with at least one comparison by race or ethnicity.

Data Extraction and Synthesis: We synthesized effect sizes using random effects meta-analysis for Blacks, Hispanics, and Asians as well as for all minority groups combined. We stratified results by source of vaccination data (self-reported or provider-verified). We used meta-regression to identify study characteristics associated with the size and direction of racial/ethnic differences in vaccination.

Main Outcomes and Measures: The effect size was the risk difference, the percentage point difference between White and one or more racial or ethnic minority groups in HPV vaccine initiation and in follow-through.

Results: HPV vaccine initiation showed no racial or ethnic differences overall. However, among studies of provider-verified vaccination, minorities were 6.1% [3.3%-8.8%] more likely than Whites to initiate HPV vaccination. This reverse disparity was larger for Hispanics, males, and younger samples (age &lt;18). In contrast, minorities were 8.6% (5.6%, 11.7%) less likely than Whites to follow-through with the full HPV vaccine series, a disparity present across all participant and study characteristics.

Conclusions and Relevance: Racial and ethnic minorities are more likely to initiate but less likely to follow through with HPV vaccination, a clear finding that self-report studies have obscured. Efforts to promote HPV vaccination should be broad, as uptake remains low across all racial and ethnic groups. Nevertheless, higher initiation among minorities offers potential for future reductions in HPV cancer disparities and may provide insights for reducing disparities in uptake of other preventive services.

Citation Format: Jennifer C. Spencer, William Calo, Noel T. Brewer. Racial and ethnic disparities and reverse disparities in HPV vaccination: A meta-analysis [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B122.