Public misperception that very low nicotine cigarettes are less carcinogenic

OBJECTIVE

The USA is considering a very low nicotine content (VLNC) cigarette standard. We sought to characterise the prevalence and correlates of the incorrect belief that VLNC cigarettes are less carcinogenic than current cigarettes, as this could reduce motivation to quit.

METHODS

Participants were a nationally representative sample of 650 adult smokers in the USA. In 2015-2016, before the VLNC proposal became public, these smokers took part in an online survey. We used multivariate weighted analyses to calculate ORs and percentages and a χ² test to examine the association between variables.

RESULTS

Overall, 47.1% of smokers believed that smoking VLNC cigarettes for 30 years would be less likely to cause cancer than smoking current cigarettes. This misperception was more common among smokers who were aged above 55 (56.6%) and black (57.4%). Additionally, 23.9% of smokers reported they would be less likely to quit if the USA adopted a VLNC standard. Thinking that VLNC cigarettes would be less carcinogenic was associated with smokers reporting they would be less likely to quit (P<0.01).

CONCLUSIONS

Many smokers had the misperception that smoking VLNC cigarettes is less likely to cause cancer, and some stated that they would be less likely to quit. A VLNC standard may be more effective if accompanied by a communication campaign that emphasises the continued dangers of smoking VLNC cigarettes due to the many toxic chemicals in smoke.

Messages to Motivate Human Papillomavirus Vaccination: National Studies of Parents and Physicians

BACKGROUND

Physician communication about human papillomavirus (HPV) vaccine is a key determinant of uptake. To support physician communication, we sought to identify messages that would motivate HPV vaccination.

METHODS

From 2014 to 2015, we surveyed national samples of parents of adolescents ages 11 to 17 (n = 1,504) and primary care physicians (n = 776). Parents read motivational messages, selected from nine longer messages developed by the Centers for Disease Control and Prevention and six brief messages developed by the study team. Parents indicated whether each message would persuade them to get HPV vaccine for their adolescents. Physicians read the brief messages and indicated whether they would use them to persuade parents to get HPV vaccine for 11- to 12-year-old children.

RESULTS

The highest proportion of parents (65%) and physicians (69%) found this brief message to be persuasive: "I strongly believe in the importance of this cancer-preventing vaccine for [child's name]." Parents disinclined to vaccinate were most receptive to messages with information about HPV infection being common, cancers caused by HPV, and HPV vaccine effectiveness. Parents' endorsement did not vary by race/ethnicity, education, child age, or child sex (all P > 0.05).

CONCLUSIONS

Our national surveys of parents and physicians identified messages that could motivate HPV vaccination, even among parents disinclined to vaccinate their children. The lack of difference across demographic subgroups in parental endorsement may suggest that these messages can be used across these subgroups.

IMPACT

Our findings support physicians' use of these messages with parents to help motivate uptake of this important cancer-preventing vaccine. Cancer Epidemiol Biomarkers Prev; 25(10); 1383-91. ©2016 AACR.

Mailed Human Papillomavirus Self-Collection With Papanicolaou Test Referral for Infrequently Screened Women in the United States

BACKGROUND

Testing for high-risk human papillomavirus (HPV) infection using mailed, self-collected samples is a promising approach to increase screening in women who do not attend clinic screening at recommended intervals.

METHODS

To assess this intervention among high-risk women in the United States, 429 women without a Papanicolaou (Pap) test in 4 or more years (overdue by US guidelines) were recruited from the general population. Participants aged 30 to 65 years were mailed a kit to self-collect a cervicovaginal sample at home, return the sample by mail, and receive HPV results by telephone, with referral to follow-up cytological Pap testing at a local clinic. Cervicovaginal self-samples were collected with a Viba brush, stored in Scope mouthwash, and tested by Hybrid Capture 2. Data were collected in 2010 to 2011 and analyzed in 2017.

RESULTS

Two-thirds (64%) of participants returned a self-collected sample, of whom 15% tested HPV DNA positive. Human papillomavirus self-test-positive women reported higher rates of follow-up Pap tests (82%) than did those with self-test negative results (51%). No demographic differences were found in self-test return rate or HPV positivity. High acceptability was reported in participant surveys: most women (81%) had "mostly positive" overall thoughts about the self-test, and most reported being comfortable receiving the kit in the mail (99%), returning their self-collected sample by mail (82%), and receiving their test results by telephone (97%).

CONCLUSIONS

Conducting HPV self-testing through population-based recruitment, mailed kit delivery and return by mail, and results delivery by telephone has the potential to reach a broad segment of US underscreened women.

Identifying principles for effective messages about chemicals in cigarette smoke

US law requires the Food and Drug Administration (FDA) to disclose information on harmful and potentially harmful chemicals in cigarette smoke (i.e., constituents) to the public. To inform this effort, we sought to identify principles for creating constituent messages that effectively discourage smoking. Participants were an online convenience sample of 1148 US smokers ages 18+. We developed a library of 76 messages about constituents only and constituents plus contextualizing information (i.e., toxic products that also contain the chemical, health effects, or both). We randomized smokers to receive 1 message from each of 7 message panels in a mixed between-/within-subjects experiment. Participants rated each message on perceived message effectiveness. Results indicated that smokers perceived messages about arsenic, formaldehyde, lead, uranium, and ammonia as more effective than messages about nitrosamines. Messages that contained information on toxic products, health effects, or both received higher effectiveness ratings than constituent-only messages. Among constituent-only messages, those that referenced multiple constituents received higher effectiveness ratings than those with fewer constituents. We conclude that chemical messages may have more impact if they pair known constituents with toxic product or health effect information. These message principles can be used to inform studies examining the impact of constituent messages on smoking beliefs and behavior.

Negative affect, message reactance and perceived risk: how do pictorial cigarette pack warnings change quit intentions?

OBJECTIVE

Pictorial warnings on cigarette packs increase motivation to quit smoking. We sought to examine the potential mediating role of negative affect, message reactance (ie, an oppositional reaction to a message) and perceived risk in shaping quit intentions.

METHODS

In 2014 and 2015, we randomly assigned 2149 adult US smokers to receive either pictorial warnings or text-only warnings applied to their cigarette packs for 4 weeks. Analyses used structural equation modelling with bootstrapped SEs to test our theorised mediational model.

FINDINGS

Pictorial warnings increased negative affect, message reactance and quit intentions (all P<0.001), but not perceived risk (ie, perceived likelihood and severity of harms of smoking). Negative affect mediated the impact of pictorial warnings on quit intentions (mediated effect=0.16, P<0.001). Message reactance weakened the impact of pictorial warnings on quit intentions, although the effect was small (mediated effect=-0.04, P<0.001). Although pictorial warnings did not directly influence perceived risk, the model showed additional small mediation effects on quit intentions through negative affect and its positive association with perceived risk (mediated effect=0.02, P<0.001), as well as reactance and its negative association with perceived risk (mediated effect=-0.01, P<0.001).

CONCLUSIONS

Pictorial cigarette pack warnings increased quit intentions by increasing negative affect. Message reactance partially attenuated this increase in intentions. The opposing associations of negative affect and reactance on perceived risk may explain why pictorial warnings did not lead to observable changes in perceived risk.

Design of a randomized clinical trial of a colorectal cancer screening decision aid to promote appropriate screening in community-dwelling older adults

BACKGROUND

Appropriate colorectal cancer screening in older adults should be aligned with the likelihood of net benefit. In general, patient decision aids improve knowledge and values clarity, but in older adults, they may also help patients identify their individual likelihood of benefit and foster individualized decision-making. We report on the design of a randomized clinical trial to understand the effects of a patient decision aid on appropriate colorectal cancer screening. This report includes a description of the baseline characteristics of participants.

METHODS

English-speaking primary care patients aged 70-84 years who were not currently up to date with screening were recruited into a randomized clinical trial comparing a tailored colorectal cancer screening decision aid with an attention control. The intervention group received a decision aid that included a values clarification exercise and individualized decision-making worksheet, while the control group received an educational pamphlet on safe driving behaviors. The primary outcome was appropriate screening at 6 months based on chart review. We used a composite measure to define appropriate screening as screening for participants in good health, a discussion about screening for patients in intermediate health, and no screening for patients in poor health. Health state was objectively determined using patients' Charlson Comorbidity Index score and age.

RESULTS

A total of 14 practices in central North Carolina participated as part of a practice-based research network. In total, 424 patients were recruited to participate and completed a baseline visit. Overall, 79% of participants were White and 58% female, with a mean age of 76.8 years. Patient characteristics between groups were similar by age, gender, race, education, insurance coverage, or work status. Overall, 70% had some college education or more, 57% were married, and virtually all had Medicare insurance (90%). The three primary medical conditions among the cohort were a history of diabetes, pneumonia, and cancer (28%, 26%, and 21%, respectively).

CONCLUSION

We designed a randomized clinical trial to test a novel use of a patient decision aid to promote appropriate colorectal cancer screening and have recruited a diverse study population that seems similar between the intervention and control groups. The study should be able to determine the ability of a patient decision aid to increase individualized and appropriate colorectal cancer screening.

Systematic Review of Measures Used in Pictorial Cigarette Pack Warning Experiments

BACKGROUND

We sought to describe characteristics and psychometric properties of measures used in pictorial cigarette pack warning experiments and provide recommendations for future studies.

METHODS

Our systematic review identified 68 pictorial cigarette pack warning experiments conducted between 2000 and 2016 in 22 countries. Two independent coders coded all studies on study features, including sample characteristics, theoretical framework, and constructs assessed. We also coded measurement characteristics, including construct, number of items, source, reliability, and validity.

RESULTS

We identified 278 measures representing 61 constructs. The most commonly assessed construct categories were warning reactions (62% of studies) and perceived effectiveness (60%). The most commonly used outcomes were affective reactions (35%), perceived likelihood of harm (22%), intention to quit smoking (22%), perceptions that warnings motivate people to quit smoking (18%), and credibility (16%). Only 4 studies assessed smoking behavior. More than half (54%) of all measures were single items. For multi-item measures, studies reported reliability data 68% of the time (mean α = 0.88, range α = 0.68-0.98). Studies reported sources of measures only 33% of the time and rarely reported validity data. Of 68 studies, 37 (54%) mentioned a theory as informing the study.

CONCLUSIONS

Our review found great variability in constructs and measures used to evaluate the impact of cigarette pack pictorial warnings. Many measures were single items with unknown psychometric properties. Recommendations for future studies include a greater emphasis on theoretical models that inform measurement, use of reliable and validated (preferably multi-item) measures, and better reporting of measure sources.

IMPLICATIONS

Robust and consistent measurement is important for building a strong, cumulative evidence base to support pictorial cigarette pack warning policies. This systematic review of experimental studies of pictorial cigarette warnings demonstrates the need for standardized, theory-based measures.

Acceptability and ease of use of mailed HPV self-collection among infrequently screened women in North Carolina

OBJECTIVES

Self-collection of cervico-vaginal samples for human papillomavirus (HPV) testing has the potential to make cervical cancer screening more accessible to underscreened women. We evaluated the acceptability and ease of use of home-based HPV self-collection within a diverse population of low-income, infrequently screened women.

METHODS

Participants were low-income women from North Carolina who had not received Pap testing in 4 or more years. Eligible women received a self-collection kit containing instructions and a brush for home-based sample collection. A total of 227 women returned a self-collected sample by mail and completed a questionnaire to assess their experiences with HPV self-collection. We described acceptability measures and used logistic regression to identify predictors of overall positive thoughts about the self-collection experience.

RESULTS

Nearly all women were willing to perform HPV self-collection again (98%) and were comfortable receiving the self-collection kit in the mail (99%). Overall, 81% of participants reported positive thoughts about home-based self-collection. Women with at least some college education and those who were divorced, separated or widowed were more likely to report overall positive thoughts. Aspects of self-collection that participants most commonly reported liking included convenience (53%), ease of use (32%) and privacy (23%). The most frequently reported difficulties included uncertainty that the self-collection was done correctly (16%) and difficulty inserting the self-collection brush (16%).

CONCLUSIONS

Home-based self-collection for HPV was a highly acceptable screening method among low-income, underscreened women and holds the promise to increase access to cervical cancer screening in this high-risk population.

Pediatrician-Parent Conversations About Human Papillomavirus Vaccination: An Analysis of Audio Recordings

PURPOSE

We sought to establish which human papillomavirus (HPV) vaccine communication approaches by pediatricians were associated with same-day HPV vaccination of 11- to 12-year-olds by evaluating audio recordings of visits.

METHODS

Verilogue, a market research company maintaining a panel of primary care pediatricians, provided audio recordings and transcriptions of well-child visits for 11- to 12-year-old patients from January through June 2013. Seventy-five transcripts from 19 pediatricians were coded for use of presumptive language (i.e., words conveying assumption of vaccine delivery), offer of delay, recommendation strength, and information provision. Using logistic regression, we evaluated the association between pediatrician communication approaches and agreement to same-day HPV vaccination. Generalized estimating equations accounted for clustering of patients within pediatricians.

RESULTS

Same-day agreement to HPV vaccination occurred in 29% of encounters. Pediatricians in the sample often provided parents with inconsistent, mixed messages and sometimes offered information about HPV or HPV vaccination that was inaccurate. Pediatricians used presumptive language in only 11 of 75 encounters; when used, presumptive language was associated with higher odds of accepting HPV vaccine (73% vs. 22%; odds ratio = 8.96; 95% confidence interval = 2.32-34.70). Pediatricians offered or recommended delay in most encounters (65%). HPV vaccine acceptance occurred far more often when pediatricians did not mention delaying vaccination (82% vs. 6%; odds ratio = 80.84; 95% confidence interval = 15.72-415.67). Same-day vaccination was not associated with strength of recommendation or pediatrician reference to vaccinating their own children.

CONCLUSIONS

Our findings highlight the need to develop and evaluate physician-focused trainings on using presumptive language for same-day HPV vaccination.

How people think about the chemicals in cigarette smoke: a systematic review

Laws and treaties compel countries to inform the public about harmful chemicals (constituents) in cigarette smoke. To encourage relevant research by behavioral scientists, we provide a primer on cigarette smoke toxicology and summarize research on how the public thinks about cigarette smoke chemicals. We systematically searched PubMed in July 2016 and reviewed citations from included articles. Four central findings emerged across 46 articles that met inclusion criteria. First, people were familiar with very few chemicals in cigarette smoke. Second, people knew little about cigarette additives, assumed harmful chemicals are added during manufacturing, and perceived cigarettes without additives to be less harmful. Third, people wanted more information about constituents. Finally, well-presented chemical information increased knowledge and awareness and may change behavior. This research area is in urgent need of behavioral science. Future research should investigate whether educating the public about these chemicals increases risk perceptions and quitting.

Parents' willingness to get human papillomavirus vaccination for their adolescent children at a pharmacy

Pharmacies are promising alternative settings for human papillomavirus (HPV) vaccination because of their accessibility and existing infrastructure for vaccine delivery. We sought to examine parents' willingness to get HPV vaccination for their children at pharmacies. In 2014, we conducted a national, online survey of 1255 parents of 11- to 17-year-old adolescents in the United States. We used multivariable logistic regression to model parents' willingness for getting HPV vaccinations in pharmacies. Overall, 29% of parents would be willing to get HPV vaccine for their children at a pharmacy. Parental willingness was associated with believing that pharmacists are skilled at administering vaccines (OR=2.05, 95% CI:1.68-2.51), HPV vaccine was at least as important as other adolescent vaccines (OR=1.48, 95% CI:1.10-1.98), and getting vaccines in pharmacies would give children more opportunities to get health care (OR=2.17, 95% CI:1.63-2.89). Parental willingness was also more common among parents of adolescents ages 13-17 or who had already initiated the HPV vaccine series. Parents most often indicated that they would like to learn about HPV vaccination in pharmacies from their children's doctor (37%). Offering HPV vaccine in pharmacies may increase uptake as a meaningful number of parents would get the vaccine for their children in these settings. Physician referrals for completing the HPV vaccine series may serve as an important source for increasing awareness of and demand for adolescent vaccination services in pharmacies.

Effects of Strengthening Cigarette Pack Warnings on Attention and Message Processing: A Systematic Review

The current study sought to examine the impact of strengthening cigarette pack warnings on attention, message processing, and perceived effectiveness, through a systematic review of longitudinal observational studies. The review included 22 studies (N = 81,824 participants). Strengthened warnings increased attention to warnings, recall of warnings, and thinking about the health risks of smoking. Strengthened warnings also increased several perceived effectiveness outcomes, including perceptions that warnings reduce smoking and motivate quitting. Strengthened cigarette pack warnings achieve their goal of attracting attention and enhancing motivation to act. Strengthening warning policies should be a priority for tobacco control globally.

Social identity and support for counteracting tobacco company marketing that targets vulnerable populations

RATIONALE

Tobacco companies use advertising to target vulnerable populations, including youth, racial/ethnic minorities, and sexual minorities.

OBJECTIVE

We sought to examine how personal identity affects support for population-specific anti-smoking advertisements that could serve as countermeasures to industry marketing practices.

METHODS

In 2014-2015, we surveyed probability phone samples of adults and adolescents (n = 6,139) and an online convenience sample of adults (n = 4,137) in the United States. We experimentally varied the description of tobacco industry marketing practices (no description, general, or specific to a target group). The four prevention target groups were teens; African Americans; Latinos; and gays, lesbians, and bisexuals (GLBs). Participants were either members or non-members of their prevention target group.

RESULTS

Support was highest for anti-smoking advertisements targeting teens, moderate for Latinos and African Americans, and lowest for GLBs. In-group members expressed higher support than out-group members when anti-smoking advertisements targeted African Americans, Latinos, and GLBs (all p < 0.05). However, when teens were the target prevention group, in-group members expressed lower support than out-group members (p < 0.05). The description of industry marketing practices did not have an effect. Results were similar across the phone and online studies.

CONCLUSIONS

Our findings suggest that the public strongly supports advertisements to prevent smoking among teens, but support for similar efforts among other vulnerable populations is comparatively low. Anti-smoking campaigns for vulnerable populations may benefit from a greater understanding of the role of social identity in shaping public support for such campaigns.

Communicating about cigarette smoke constituents: an experimental comparison of two messaging strategies

Federal law now requires FDA to disseminate information on chemicals in cigarette smoke, but it is unclear how best to do so. In a 2 × 2 between-subjects experiment, participants received a message about chemicals in cigarette smoke (e.g., "Cigarette smoke has benzene.") along with an additional randomly assigned messaging strategy: a "found-in" (e.g., "This is found in gasoline."), a health effect (e.g., "This causes heart disease."), both, or neither. Participants were U.S. probability phone samples of 5000 adults and 1123 adolescents, and an online convenience sample of 4130 adults. Adding a health effect elicited greater discouragement from wanting to smoke cigarettes (all p < .05) as did adding a found-in (all p < .05). However, including both messaging strategies added little or nothing above including just one. These findings can help the FDA and other agencies develop effective and parsimonious messages about cigarette smoke constituents.

How hearing about harmful chemicals affects smokers' interest in dual use of cigarettes and e-cigarettes

Substantial harm could result from concurrent cigarette and e-cigarette use (i.e., dual use) were it to undermine smoking cessation. Perceptions of chemical exposure and resulting harms may influence dual use. We conducted a probability-based phone survey of 1164 U.S. adult cigarette smokers in 2014-2015 and analyzed results in 2016. In a between-subjects experiment, smokers heard a hypothetical scenario in which cigarettes and e-cigarettes had the same amount of harmful chemicals or cigarettes had more chemicals than e-cigarettes (10× more, 100× more, or chemicals were present only in cigarettes). Smokers indicated how the scenario would change their interest in dual use and perceived health harms. Few smokers (7%) who heard that the products have the same amount of chemicals were interested in initiating or increasing dual use. However, more smokers were interested when told that cigarettes have 10× more chemicals than e-cigarettes (31%), 100× more chemicals than e-cigarettes (32%), or chemicals were present only in cigarettes (43%) (all p<.001). Individuals told that cigarettes have more chemicals were more likely than those in the "same amount" scenario to perceive that cigarettes would be more harmful than e-cigarettes (79% vs. 41%, OR=5.41, 95% CI=4.08-7.17). These harm perceptions partially explained the relationship between chemical scenario and dual use interest. Smokers associated higher chemical amounts in cigarettes versus e-cigarettes with greater health harms from cigarettes and thus expressed increased interest in dual use. The findings suggest that disclosing amounts of chemicals in cigarette smoke and e-cigarette aerosol could unintentionally encourage dual use.

Opportunities and Challenges of Adolescent and Adult Vaccination Administration Within Pharmacies in the United States

Pharmacies have been endorsed as alternative vaccine delivery sites to improve vaccination rates through increased access to services. Our objective was to identify challenges and facilitators to adolescent and adult vaccination provision in pharmacy settings in the United States. We recruited 40 licensed pharmacists in states with different pharmacy vaccination laws. Eligible pharmacists previously administered or were currently administering human papillomavirus (HPV); tetanus, diphtheria, and pertussis (TDAP); or meningitis (meningococcal conjugate vaccine [MCV4]) vaccines to adolescents aged 9 to 17 years. Pharmacists participated in a semistructured survey on in-pharmacy vaccine provision. Pharmacists commonly administered vaccinations to age-eligible adolescents and adults: influenza (100%, 100%), pneumococcal (35%, 98%), TDAP (80%, 98%), MCV4 (60%, 78%), and HPV (45%, 53%). Common challenges included reimbursement/insurance coverage (28%, 78%), education of patients/parents (30%, 40%), and pharmacists' time constraints (28%, 35%). Three-quarters of pharmacists reported that vaccination rates could be increased. National efforts should expand insurance coverage for vaccine administration reimbursement and improve data information systems to optimize provision within pharmacies.

Human Papillomavirus Awareness in Haiti: Preparing for a National HPV Vaccination Program

STUDY OBJECTIVE

Cervical cancer morbidity and mortality are pressing public health issues that affect women in Haiti. To inform efforts to develop a human papillomavirus (HPV) vaccination program in Haiti, we sought to understand HPV awareness and willingness to get HPV vaccination in Haiti.

DESIGN, SETTING, AND PARTICIPANTS

We interviewed a convenience sample of 475 women and men in 2 clinical settings in Port-au-Prince and Léogâne, Haiti between April and July 2014.

INTERVENTIONS AND MAIN OUTCOME MEASURES

HPV awareness and willingness to get HPV vaccine for daughters.

RESULTS

Few participants (27%, 130/475) had heard of HPV. Awareness of HPV was higher among respondents with a previous sexually transmitted infection compared with those without a previous sexually transmitted infection (odds ratio, 2.38; 95% confidence interval, 1.10-5.13). Adults who had heard of genital warts were also more likely to be aware of HPV compared with those who had not (odds ratio, 4.37; 95% confidence interval, 2.59-7.38). Only 10% (24/250) of parents had previously heard of HPV vaccine; however, after researchers explained the purpose of the vaccine, nearly all (96%, 240/250) said they would be willing to get HPV vaccine for their daughters if it were available.

CONCLUSION

Despite low awareness of HPV in Haiti, interest in HPV vaccination was nearly universal in our study of health care-seeking adults. This high acceptability suggests that HPV vaccination programs instituted in Haiti would be well received.

Development and Validation of a Genomic Knowledge Scale to Advance Informed Decision Making Research in Genomic Sequencing

Background

This study evaluated the psychometric properties of a new, comprehensive measure of knowledge about genomic sequencing, the University of North Carolina Genomic Knowledge Scale (UNC-GKS).

Methods

The UNC-GKS assesses knowledge in four domains thought to be critical for informed decision making about genomic sequencing. The scale was validated using classical test theory and item response theory in 286 adult patients and 132 parents of pediatric patients undergoing diagnostic whole exome sequencing (WES) in the NCGENES study.

Results

The UNC-GKS assessed a single underlying construct (genomic knowledge) with good internal reliability (Cronbach's alpha = 0.90). Scores were most informative (able to discriminate between individuals with different levels of genomic knowledge) at one standard deviation above the scale mean or lower, a range that included most participants. Convergent validity was supported by associations with health literacy and numeracy (rs=0.41-0.46). The scale functioned well across subgroups differing in sex, race/ethnicity, education, and English proficiency.

Discussion

Findings supported the promise of the UNC-GKS as a valid and reliable measure of genomic knowledge among people facing complex decisions about WES and comparable sequencing methods. It is neither disease- nor population-specific, and it functioned well across important subgroups, making it usable in diverse populations.

A brief measure of reactance to health warnings

Reactance to persuasive messages involves perceived threat to freedom, anger, and counterarguing that may undermine the impact of health warnings. To understand reactance's effects, reliable and valid assessment is critical. We sought to develop and validate a brief Reactance to Health Warnings Scale (RHWS). Two independent samples of US adults completed the brief RHWS in studies that presented warnings on cigarette packs that smokers carried with them for 4 weeks (Study 1; n = 2149) or as digital images of cigarette packs that participants viewed briefly (Study 2; n = 1413). The three-item Brief RHWS had good internal consistency and test-retest reliability. The scale correlated with higher trait reactance and exposure to pictorial warnings, supporting its convergent validity. With respect to predictive validity, the Brief RHWS predicted perceived message effectiveness, quit intentions, avoidance of the warnings, and number of cigarettes smoked per day. The Brief RHWS can serve as an efficient adjunct to the development of persuasive messages.

Communicating Tobacco Product Information to the Public

The 2009 Family Smoking Prevention and Tobacco Control Act (TCA) requires tobacco companies to disclose information about the harmful chemicals in their products to the U.S. Food and Drug Administration (FDA). The law requires the FDA, in turn, to communicate this information to the public "in a format that is understandable and not misleading to a lay person." But how should the FDA comply with this requirement? What does it mean for information about complex chemicals to be "understandable and not misleading to a lay person"? These questions are not easy ones to answer. Disclosures about the amount of harmful chemicals (constituents) in different tobacco products may help to inform consumers, but may also conversely prompt consumers to reach incorrect or unsupported conclusions about products' relative health risks. This paper first analyzes the FDA's legal obligation to publish tobacco constituent information so that it is "understandable and not misleading to a layperson." Second, it discusses how that legal analysis has guided scientific research examining how members of the public interpret messages regarding tobacco constituents. Lastly, this paper concludes with policy recommendations for the FDA as it considers how to comply with the law's constituent disclosure requirement while still furthering its overall objective of promoting public health.

Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial

OBJECTIVE

Improving provider recommendations is critical to addressing low human papillomavirus (HPV) vaccination coverage. Thus, we sought to determine the effectiveness of training providers to improve their recommendations using either presumptive "announcements" or participatory "conversations."

METHODS

In 2015, we conducted a parallel-group randomized clinical trial with 30 pediatric and family medicine clinics in central North Carolina. We randomized clinics to receive no training (control), announcement training, or conversation training. Announcements are brief statements that assume parents are ready to vaccinate, whereas conversations engage parents in open-ended discussions. A physician led the 1-hour, in-clinic training. The North Carolina Immunization Registry provided data on the primary trial outcome: 6-month coverage change in HPV vaccine initiation (≥1 dose) for adolescents aged 11 or 12 years.

RESULTS

The immunization registry attributed 17 173 adolescents aged 11 or 12 to the 29 clinics still open at 6-months posttraining. Six-month increases in HPV vaccination coverage were larger for patients in clinics that received announcement training versus those in control clinics (5.4% difference, 95% confidence interval: 1.1%-9.7%). Stratified analyses showed increases for both girls (4.6% difference) and boys (6.2% difference). Patients in clinics receiving conversation training did not differ from those in control clinics with respect to changes in HPV vaccination coverage. Neither training was effective for changing coverage for other vaccination outcomes or for adolescents aged 13 through 17 (n = 37 796).

CONCLUSIONS

Training providers to use announcements resulted in a clinically meaningful increase in HPV vaccine initiation among young adolescents.