U.S. adults' addiction and harm beliefs about nicotine and low nicotine cigarettes

Effects of Framing Nicotine Reduction in Cigarettes on Anticipated Tobacco Product Use Intentions and Risk Perceptions Among US Adult Smokers

Introduction

In 2017, the US Food and Drug Administration (FDA) proposed lowering the amount of nicotine in combusted cigarettes to minimally addictive levels. If used, to encourage cessation and maximize the benefits of this action, the FDA needs to determine the most effective way to communicate to the public the practical impact of this nicotine tobacco product standard.

Methods

Data were collected in 2018 from a nationally representative, online probability sample of 1198 adult smokers (aged ≥18 years old) in the United States. Smokers were randomly assigned one of five versions of the question regarding what they would most likely do if nicotine in cigarettes was reduced (nicotine levels were reduced by 95%; the government reduced nicotine levels by 95%; cigarettes were no longer addictive; cigarettes no longer relieved cravings; cigarettes were changed so that you would be able to quit more easily). Effects of framing on anticipated tobacco use intentions and perceived risk of very low nicotine cigarettes (VLNCs) were evaluated with multinomial logistic regressions.

Results

Framing the nicotine tobacco product standard as cigarettes no longer relieved cravings resulted in the highest proportion of smokers reporting they intend to quit in response to this standard (43.9%), lowest proportions reporting anticipated intentions to continue using combusted tobacco products (45.3%), and lowest proportion believing that VLNCs are less harmful than regular cigarettes (26%).

Conclusions

Different frames of nicotine reduction in cigarettes differentially affected smokers’ anticipated tobacco use intentions and perceived risk of VLNCs. Presenting reduction as making cigarettes unable to relieve cravings might be particularly effective at motivating cessation.

Communicating the relative health risks of E-cigarettes: An online experimental study exploring the effects of a comparative health message versus the EU nicotine addiction warnings on smokers' and non-smokers' risk perceptions and behavioural intentions

INTRODUCTION

This study investigated the effects of the European Union Tobacco Products Directive [EU-TPD] Article 20 E-cigarette (EC) health warnings ("This product contains nicotine which is a highly addictive substance. [It is not recommended for non-smokers.]") and a comparative harm message ("Use of this product is much less harmful than smoking" [COMP]) on smokers' and non-smokers' perceptions and behavioural intentions.

METHODS

2495 UK residents (1283 smokers and 1212 non-smokers) self-reported perceived harm, addictiveness, EC effectiveness, social acceptability, and intentions to purchase and use EC, and in smokers, intentions to quit and intentions to use EC in future quit attempts. These were measured before and after exposure to EC images containing either the TPD, COMP, TPD + COMP or no message.

RESULTS

Non-smokers had higher harm, addictiveness and lower social acceptability perceptions. TPD presence increased, whilst COMP decreased, harm and addictiveness perceptions in both groups. For smokers only, harm perceptions were lower following exposure to COMP alone vs. no message. For non-smokers the TPD increased harm perceptions vs. no message. There were no effects on social acceptability, EC effectiveness or use intentions. In smokers only, purchase and quit intentions were higher following exposure to the COMP alone.

CONCLUSION

TPD messages may be effective smoking prevention tools, although the COMP message was more effective in reducing harm perceptions and increasing use intentions in smokers. That COMP did not increase use intentions in non-smokers suggest that such exposures may potentially act as an effective harm reduction tool without resulting in increased uptake among non-smokers.

Effects of Cigarette Nicotine Content and Menthol Preference on Perceived Health Risks, Subjective Ratings, and Carbon Monoxide Exposure Among Adolescent Smokers

INTRODUCTION

Minimal research exists on adolescent smokers' perceptions of very low-nicotine-content (VLNC) cigarettes. As approximately half of adolescent smokers prefer menthol cigarettes, it is important to consider the influence of menthol preference on VLNC cigarette perceptions and to what extent menthol preference may affect VLNC smoking behavior. This study examined the effects of cigarette nicotine content and menthol preference or menthol smoking on health risk perceptions, subjective ratings, and carbon monoxide (CO) boost in adolescent smokers.

METHODS

Across two counterbalanced sessions, adolescent smokers sampled VLNC and normal nicotine content (NNC) research cigarettes following overnight abstinence. Cigarettes were mentholated or non-mentholated consistent with participants' usual brand. In each session, participants smoked the research cigarette and then completed the Perceived Health Risk Scale and Cigarette Evaluation Scale. Breath CO readings were obtained pre- and post-smoking. Mixed-factor ANOVA tests compared outcomes with cigarette type (VLNC vs. NNC) as the within-subjects factor and menthol preference as the between-subjects factor.

RESULTS

Participants (N = 50) were M = 17.7 years old, smoked M = 8.2 cigarettes/day, and 56% typically smoked menthol cigarettes. Participants reported lower risk of developing lung cancer, other cancers, emphysema, bronchitis, and heart disease (ps ≤ .05) when smoking VLNC cigarettes relative to NNC cigarettes. Perceived risk of addiction and stroke did not differ by nicotine content. Menthol preference or menthol smoking did not moderate risk perceptions, subjective ratings, or CO boost.

CONCLUSIONS

Adolescents may incorrectly perceive that VLNC cigarettes are less harmful products. Health communication campaigns could help to correct VLNC misperceptions and potentially minimize unintended consequences of a nicotine reduction policy.

Reducing Nicotine Without Misleading the Public: Descriptions of Cigarette Nicotine Level and Accuracy of Perceptions About Nicotine Content, Addictiveness, and Risk

SIGNIFICANCE

The public incorrectly believes very low nicotine content (VLNC) cigarettes are less carcinogenic than current cigarettes, a belief associated with lower motivation to quit under a VLNC standard. We examined how different descriptions of the nicotine level in VLNC cigarettes affect the accuracy of the public's perceptions about nicotine content, addictiveness, and cancer risk.

METHODS

Participants were a national convenience sample of 1353 US adults (22% smokers). In an online experiment, we randomized participants to a VLNC description using (1) concise language; (2) a percentage; (3) an interpretation; (4) a percentage and interpretation; (5) a percentage and a pictograph; or (6) a percentage, interpretation, and pictograph; or to a control description using (7) FDA's "minimally or nonaddictive" phrasing. We assessed accuracy of perceived nicotine content, addictiveness, and cancer risk compared to current cigarettes.

RESULTS

Compared to control, the percentage description resulted in more accurate perceptions about nicotine content (76% vs. 49% accuracy) and addictiveness (44% vs. 34%), but less accurate perceptions about cancer risk (56% vs. 68%; all ps < .05). Adding interpretation or pictographs to the percentage description did not increase accuracy. The concise language description reduced accuracy of perceived nicotine content and addictiveness but increased accuracy of cancer risk (all ps < .05).

CONCLUSIONS

Stating that 95% of nicotine would be removed more accurately conveyed the nicotine content and addictiveness of VLNC cigarettes. However, descriptions that better conveyed nicotine content and addictiveness misled people about cancer risk.

IMPLICATIONS

Implementation of a VLNC standard should include plans for a communication campaign that conveys that VLNC cigarettes will be less addictive but equally toxic to smoke. Stating the percent reduction in nicotine is likely to more clearly communicate reduced addictiveness but may also exacerbate risk misperceptions. VLNC communication requires further study to ensure the public accurately understands a VLNC standard.

Effects of a Nicotine Fact Sheet on Perceived Risk of Nicotine and E-Cigarettes and Intentions to Seek Information About and Use E-Cigarettes

We examined how a nicotine fact sheet influenced smokers’ beliefs about nicotine and electronic cigarettes (e-cigarettes), a potentially less harmful alternative to conventional cigarettes. In an exploratory online experiment, 756 US adult current and recent former smokers (quit in the past 2 years) were randomized to view a nicotine fact sheet or control messages (bottled water ads). Effects of the nicotine fact sheet on perceived nicotine addictiveness, nicotine risk, comparative risk of e-cigarettes, and dual use intentions were analyzed using log-Poisson regression with robust error. Linear regression analyzed effects on perceived absolute risk and switching and information seeking intentions about e-cigarettes. Compared to control, the nicotine fact sheet doubled the probability of disagreeing that nicotine is the main cause of smoking-related disease (26.2% vs. 12.7%, RR = 2.06, 95% CI = 1.51, 2.82, p < 0.001). However, nearly three quarters of participants viewing the nicotine fact sheet still thought that nicotine is the main cause of smoking-related disease. The nicotine fact sheet increased smokers’ intentions to seek information about e-cigarettes (b = 0.45, 95% CI = 0.15, 0.74, p = 0.003). We did not find evidence suggesting unintended consequences of the nicotine fact sheet on smokers’ e-cigarettes risk perceptions or use intentions (e.g., increased dual use intentions or reduced absolute e-cigarette risk perception).

Latent Classes of Nicotine Beliefs Correlate with Perceived Susceptibility and Severity of Nicotine and Tobacco Products in US young adults

BACKGROUND

Pervasive misperceptions about nicotine may influence uptake of quit smoking aids and the impact of policies addressing nicotine as a tobacco product constituent.

METHODS

Latent class analyses were conducted using four items on nicotine beliefs asked of 4037 adults aged 18-40 in wave 9 (February-March 2016) of the Truth Initiative Young Adult Cohort Study. Confirmatory factor analyses identified three factors from 12 items: nicotine susceptibility (NSUS), nicotine severity (NSEV), and tobacco severity (TSEV). Analyses assessed correlations between latent classes, sociodemographics, and nicotine/tobacco factor scores.

RESULTS

A four-class model of nicotine beliefs was the best fit, with the largest class believing that nicotine plays a major part in smoking risks (class 1, n = 2070; 52%). Class 2 shared that belief but also responded "Don't know" to addiction questions (class 2, n = 382; 11%). Fewer belonged in class 3, who reported that nicotine plays a small part in health risks (n = 1277; 30%), and class 4, who perceived nicotine as not cancer causing (n = 308; 7%). Latent class membership was correlated with sociodemographics, peer smoking, and past 30-day tobacco use. Classes 1 and 2 had similar NSUS scores and classes 3 and 4 had similar NSEV and TSEV scores.

DISCUSSION

Differences in the perceptions of nicotine and tobacco-related harms can be partially explained by clustering of underlying nicotine beliefs. These classes of beliefs are correlated with sociodemographic predictors of smoking. These findings may help to identify specific beliefs or groups to be targeted by public education efforts on nicotine.

IMPLICATIONS

The current study supports that underlying nicotine beliefs are associated with perceived harms of specific nicotine and tobacco products (relative to cigarettes), with greater false beliefs about nicotine correlated with greater perceived susceptibility to nicotine addiction. Two important inferences emerge from this study: first, that education to address nicotine beliefs may also reframe perceptions of the harms of nicotine and tobacco products; and second, that this type of education may differentially impact perceptions of the harms of nicotine products (e.g., nicotine replacement therapy and e-cigarettes) and tobacco products (e.g., cigars, smokeless, and hookah).

Smokers' behavioral intentions in response to a low-nicotine cigarette policy

INTRODUCTION

Evidence suggests that reducing the nicotine concentration in cigarettes to sub-addictive levels would reduce use. Until a low-nicotine cigarette policy is enacted, population-level effects are unknown. This study examines the behavioral intentions of current U.S. cigarette smokers if a low-nicotine policy were implemented.

METHODS

Data were drawn from a nationally representative probability-based panel and opt-in panel. Weighted logistic regressions examined likelihood to (1) smoke lower nicotine cigarettes, (2) quit using tobacco, (3) use e-cigarettes, (4) illegally buy high-nicotine cigarettes, and (5) smoke cigars, cigarillos, or little cigars (CLCCs) among smokers, controlling for demographics, tobacco products used, dependence, and intentions to quit cigarettes. Latent class analyses (LCA) characterized patterns of behavioral intentions.

RESULTS

If a low-nicotine policy were implemented, most participants indicated a likelihood to smoke low-nicotine cigarettes (78.4%) or quit tobacco (61.9%), followed by use e-cigarettes (46.5%). Individuals with greater dependence had greater odds of intending to smoke low-nicotine cigarettes, use e-cigarettes, and illegally buy high-nicotine cigarettes. Current e-cigarette or CLCCs users had higher odds of intending to use these products. LCA revealed that individuals would 1) use low-nicotine cigarettes with low intentions to use other tobacco products or 2) use multiple tobacco products, including low-nicotine cigarettes.

CONCLUSIONS

A reduced nicotine standard for all combustible tobacco products is needed given that many tobacco users would likely intend to continue to use tobacco products. Differences in intentions by tobacco use and demographic characteristics indicate a need for additional cessation support and education around the harms of continued use of combustible tobacco.

Prevalence and correlates of nicotine and nicotine product perceptions in U.S. young adults, 2016

INTRODUCTION

Nicotine is not a human carcinogen and combustion compounds in tobacco smoke, rather than nicotine, cause tobacco-related cardiovascular disease. Few recent studies examine the public's beliefs about nicotine in relation to smoking.

METHODS

Participants aged 18-40 (n = 4,091) in Wave 10 (Fall 2016) of the Truth Initiative Young Adult Cohort Study responded to nineteen items on nicotine and nicotine product perceptions, including addictiveness and health harms of nicotine patch/gum and e-cigarettes compared to cigarettes. Analyses conducted in 2018 examined prevalence of perceptions and sociodemographic and tobacco use correlates of selected perceptions.

RESULTS

The majority of young adults reported that nicotine was responsible for a "relatively" or "very large" part of the health risks (66%) and cancer (60%) caused by smoking. More than half of young adults (55%) believed that nicotine is a cause of cancer. Between 23% and 43% of young adults responded "don't know" to items on nicotine. Females, blacks, Hispanics, and those with less than some college education were more likely to report true or "don't know" vs. false to "nicotine is a cause of cancer" and had higher odds of believing that nicotine was responsible for a "relatively" or "very large" part of the health risks of smoking and cancer caused by smoking. Past 30-day tobacco users had lower odds of reporting these beliefs.

CONCLUSIONS

Misperceptions of nicotine are widespread in young adults. Public education is needed to maximize the public health impact of FDA's required nicotine warning label and proposed nicotine reduction policies.

Effects of immediate versus gradual nicotine reduction in cigarettes on biomarkers of biological effects

AIM

A previous study showed significantly greater reductions in number of cigarettes smoked and biomarkers of toxicant and carcinogen exposure in smokers assigned to immediate reduction of nicotine in cigarettes to very low levels versus gradually over time or continued smoking of normal nicotine content cigarettes. This study examines the effects of these approaches on selected biomarkers associated with harmful biological effects.

DESIGN

Three-arm, randomized controlled trial.

SETTING

Ten United States academic institutional sites.

PARTICIPANTS

Daily smokers uninterested in quitting smoking with a mean age of 45.1 [standard deviation (SD) = 13.4)] years and smoking 17.1 (SD = 8.5) cigarettes/day; 43.9% (549 of 1250) female; 60.6% (758 of 1250) white ethnicity.

INTERVENTIONS

(1) Smoking cigarettes where nicotine content was immediately reduced to very low levels (n = 503); (2) smoking cigarettes where nicotine content was gradually reduced, with dose changes occurring monthly (n = 498); and (3) continued smoking with normal nicotine content cigarettes (n = 249).

MEASUREMENTS

Smokers were assessed at baseline while smoking their usual brand cigarettes, and again at 4, 8, 12, 16 and 20 weeks. Outcomes were areas under the concentration time curve (AUC) for the period of study of biomarkers of inflammation, oxidative stress and hematological parameters.

FINDINGS

No consistent significant differences were observed across groups (Bayes factors showing data to be insensitive), with the only exception being red blood cell size variability, which was observed to be lower in the immediate versus gradual nicotine reduction [mean difference =  -0.11; 95% confidence interval (CI) = -0.18, -0.04, P = 0.004] and normal nicotine control groups (mean difference = - 0.15, 95% CI = -0.23, -0.06, P = 0.001).

CONCLUSION

It remains unclear whether switching to very low nicotine cigarettes leads to a short-term reduction in biomarkers of tobacco-related harm.

Impact of Brief Nicotine Messaging on Nicotine-Related Beliefs in a U.S. Sample

INTRODUCTION

The current study pilot tested the effect of a single, brief exposure to nicotine education messages on beliefs about nicotine, nicotine-replacement therapy (NRT), E-cigarettes, and cigarettes with reduced nicotine content (RNC).

METHODS

Five hundred and twenty-one U.S. adults (aged ≥18 years) completed a 15-minute survey on Amazon Mechanical Turk in 2018. After completing items on sociodemographics, literacy, and cancer risk behaviors, participants were randomized in a 2:1:1 ratio to 1 of 3 conditions: nicotine education (n=263), sun safety education (attention control, n=128), or no message control (n=130). All participants completed items regarding nicotine, NRT, E-cigarette, and RNC cigarette beliefs, as well as norms about nicotine use, behavioral control regarding cigarette/tobacco use, and intention to use cigarettes, NRT, E-cigarettes, and RNC cigarettes in the next 12 months. Analyses were conducted in 2019.

RESULTS

Following exposure, nicotine education participants reported fewer false beliefs about nicotine (p<0.001), NRT (p<0.001), E-cigarettes (p<0.05), and RNC cigarettes (p<0.05) compared with the control conditions. Nicotine messaging doubled the probability of a correct response (false, 78.3% vs 36.8%) to nicotine is a cause of cancer and dramatically reduced the probability of responding don't know to this item (5.3% vs 26.0%). There was no impact of the intervention on beliefs about other substances within cigarette, norms, or behavioral intentions.

CONCLUSIONS

Findings from the current study support the hypothesis that a brief nicotine messaging intervention-similar to the messages likely to be seen on warning labels or in media campaigns-is likely to correct misperceptions of nicotine, NRT, E-cigarettes, and RNC cigarettes.

Examining Risk Perceptions Among Daily Smokers Naïve to Reduced Nicotine Content Cigarettes

INTRODUCTION

The U.S. Food and Drug Administration (FDA) has stated its interest in reducing the addictiveness of combustible cigarettes by lowering their nicotine content. Delineating risk perceptions of reduced nicotine content (RNC) cigarettes prior to federal regulation may inform the content of future educational campaigns accompanying this policy.

METHODS

Five hundred non-treatment-seeking, daily smokers naïve to RNC cigarettes (63.0% male, 51.6% nonWhite, mean [SD] cigarettes per day = 15.69 [7.58], age = 43.44 [11.46]) completed a 10-item RNC cigarette risk perception questionnaire at baseline in two, unrelated experimental studies. We used multinomial logistic regression models to identify demographic (eg, gender) and smoking-related (eg, nicotine dependence) correlates of RNC cigarette risk perceptions.

RESULTS

Although the majority of participants did not misperceive RNC cigarettes as less harmful than regular or high nicotine cigarettes, a large portion of the sample held misperceptions about RNC cigarettes' addictiveness (56.4%) and cessation aid potential (63.4%). More than 20% of the sample reported being unsure about RNC-related risks, especially tar content (51.8%). NonWhite smokers were 2.5 to 3 times more likely to be incorrect about multiple RNC cigarette risks (p = .002-.006).

CONCLUSIONS

If the FDA mandates a reduced nicotine content standard for cigarettes, educational campaigns will be needed to correct misperceptions about RNC cigarettes' addictiveness and potential to aid cessation as well as inform consumers about their safety risks. Campaigns tailored toward nonWhite smokers may also be needed to correct misperceptions of RNC cigarette risks held by this subgroup.

IMPLICATIONS

The FDA has stated its interest in reducing cigarettes' addictiveness by lowering their nicotine content, enabling smokers to quit. Our findings suggest that most smokers who have not used RNC cigarettes do not perceive these products as less addictive or as cessation tools, stressing a need for future educational campaigns to correct these misperceptions. Campaigns are also needed to educate uninformed smokers about RNC cigarettes and should consider targeting messages toward subgroups likely to hold misperceptions about the risks and benefits of using these products (eg, nonWhite smokers).

Influence of Electronic Cigarette Characteristics on Susceptibility, Perceptions, and Abuse Liability Indices among Combustible Tobacco Cigarette Smokers and Non-Smokers

This study assessed how electronic cigarette (ECIG) characteristics amenable to regulation-namely nicotine content, flavor, and modified risk messages-impact ECIG use susceptibility, harm/addiction perceptions, and abuse liability indices among combustible tobacco cigarette (CTC) smokers and non-smokers. CTC smokers and non-smokers varying in ECIG use recruited via Amazon Mechanical Turk (MTurk) completed an online survey in 2016 (analytic n = 706). Participants were randomly assigned to one of eight conditions differing in ECIG characteristics: nicotine content (no, low, high), flavor (menthol, tobacco, fruit), or modified risk message (reduced harm, reduced carcinogen exposure). Regressions assessed ECIG susceptibility, harm/addiction perceptions, and abuse liability indices (purchase task measures of breakpoint/intensity) within each regulatory domain (nicotine content, flavor, message) and their interactions with CTC/ECIG status. Differential effects on ECIG susceptibility, harm/addiction perceptions, and abuse liability indices were observed by regulatory domain with many effects moderated by CTC/ECIG status. ECIG nicotine content and flavor conditions were the most influential across outcomes. Greater nicotine content, tobacco-flavored and reduced carcinogen exposure ECIGs were more highly preferred by CTC smokers with some differing preferences for non-users. Findings reinforce consideration of discrete ECIG preferences across tobacco use status to improve regulatory efficacy.

Estimating Uptake for Reduced-nicotine Cigarettes Using Behavioral Economics

Objectives

Lowering the nicotine content in combustible cigarettes may be a viable strategy for reducing dependence and toxin exposure. Understanding how marketing and education may affect initial uptake is an important avenue of inquiry prior to any policy change. There has yet to be an investigation of how framing reductions in nicotine may affect intentions to purchase and consume these cigarettes using the behavioral economic framework.

Methods

Participants from Amazon Mechanical Turk completed several tasks, including the Cigarette Purchase Task and Experimental Tobacco Marketplace, under conditions in which a new, reduced-nicotine cigarette alternative is the only cigarette available.

Results

Cigarette purchasing was largely unaffected by stated nicotine concentration, but lower concentrations suggested the potential of small estimated compensatory purchasing. Exposure to a narrative detailing how others have perceived the negative subjective effects of lower nicotine cigarettes (eg, less satisfaction) significantly reduced the perceived value of cigarettes.

Conclusions

These results suggest information about nicotine content alone is unlikely to reduce initial uptake without accompanying narratives about the effects of this reduced-nicotine content.

Evaluation of the distribution of nicotine intravenous injection: an adult autopsy case report with a review of literature

We reported the first comprehensive autopsy case of death due to intravenous injection of nicotine. We examined the distribution of nicotine in the body tissues and fluid and exposed the pathophysiology of nicotine poisoning. A 19-year-old woman was rushed to the hospital in cardiorespiratory arrest and was confirmed dead upon arrival. Liquid nicotine, hydrogen peroxide water, and a syringe were found in the hotel room where she stayed. On autopsy, nicotine concentration was the highest (15,023 μg/mg) in the tissue around the injection mark on the right upper arm. Among the body fluids, the intraperitoneal fluid had the highest, whereas the pericardial fluid had the lowest (0.736 μg/mL) nicotine concentration. Among the organs, the brain had the highest (11.637 μg/mg), whereas the fat tissue had the lowest (1.307 μg/mg) nicotine concentration. The concentration of cotinine, which is the metabolite of nicotine, was the highest in the tissue around the injection mark on the right arm (5.495 μg/mg) and was almost the same among the other body fluids and organs. The respective concentrations of nicotine and cotinine were 1.529 μg/mL and 0.019 μg/mL in the left heart blood and 3.157 μg/mL and 0.002 μg/mL in right heart blood. In this case, the nicotine concentrations in blood reached the lethal level. The distributions of nicotine and cotinine, as indicated by the intravenous injection, were related to the distribution of organs that metabolize nicotine and the distribution of nicotinic acetylcholine receptors.

Tobacco smoking and nicotine delivery alternatives: patterns of product use and perceptions in 13 countries

Background: Smoking tobacco products remains a significant public health problem. The Foundation for a Smoke-Free World commissioned a 13-country survey to gain a clearer understanding of the current landscape of smoking behavior and preferences across the world. Methods: Over 17,000 participants in 13 countries, representing different regions and income groups, answered questions on their smoking patterns and product use, their social context, their motivation to smoke, quit, or switch, and their perception of risks of products and substances. Rim weighting was done for each country to align responses with population demographics, and an additional 200 smokers for each country were surveyed to achieve sufficient sample size for sub-analyses of smoker data. Results: The observed prevalence of smoking ranged from an age-adjusted high of 57.5% in Lebanon to 8.4% in New Zealand among men, with lower rates for women. The majority of smokers were between 25-54 years old, had daily routines and social patterns associated with smoking, used boxed cigarettes, and rated their health more poorly compared to never smokers. Among a range of products and substances, smokers tended to give both cigarettes and nicotine the highest harm ratings. Smokers in high income countries were largely familiar with electronic nicotine delivery systems; the most commonly given reasons for using them were to cut down or quit smoking. A majority of smokers had tried to quit at least once, and while many tried without assistance, motivations, intentions, and methods for smoking cessation, including professional help, nicotine replacement therapies or medications, or electronic cigarettes, varied among countries. Conclusions: Smoking is deeply integrated in smokers' lives worldwide. Although a majority of smokers have tried to quit, and are concerned for their health, they do not seek help. Smokers lack understanding of the harmful components of smoking tobacco products and the risk profile of alternatives.

Tobacco smoking and nicotine delivery alternatives: patterns of product use and perceptions in 13 countries

Background: Smoking tobacco products remains a significant public health problem. The Foundation for a Smoke-Free World commissioned a 13-country survey to gain a clearer understanding of the current landscape of smoking behavior and preferences across the world. Methods: Over 17,000 participants in 13 countries, representing different regions and income groups, answered questions on their smoking patterns and product use, their social context, their motivation to smoke, quit, or switch, and their perception of risks of products and substances. Rim weighting was done for each country to align responses with population demographics, and an additional 200 smokers for each country were surveyed to achieve sufficient sample size for sub-analyses of smoker data. Results: The observed prevalence of smoking ranged from an age-adjusted high of 57.5% in Lebanon to 8.4% in New Zealand among men, with lower rates for women. The majority of smokers were between 25-54 years old, had daily routines and social patterns associated with smoking, used boxed cigarettes, and rated their health more poorly compared to never smokers. Among a range of products and substances, smokers tended to give both cigarettes and nicotine the highest harm ratings. Smokers in high income countries were largely familiar with electronic nicotine delivery systems; the most commonly given reasons for using them were to cut down or quit smoking. A majority of smokers had tried to quit at least once, and while many tried without assistance, motivations, intentions, and methods for smoking cessation, including professional help, nicotine replacement therapies or medications, or electronic cigarettes, varied among countries. Conclusions: Smoking is deeply integrated in smokers' lives worldwide. Although a majority of smokers have tried to quit, and are concerned for their health, they do not seek help. Smokers lack understanding of the harmful components of smoking tobacco products and the risk profile of alternatives.

The Impact of E-Cigarette Warnings, Warning Themes and Inclusion of Relative Harm Statements on Young Adults' E-Cigarette Perceptions and Use Intentions

Although e-cigarettes in the United States are required to carry one nicotine addiction warning, little is known about the impact of other potential e-cigarette warning themes, nor about pairing warnings with messages that communicate e-cigarettes' reduced-harm potential relative to cigarettes. We randomly assigned 876 young adults (ages 18⁻29) to view e-cigarette ads in a 3 × 2 plus control online experiment that varied by warning theme (i.e., nicotine addiction; nicotine's impact on adolescent brain development; presence of harmful chemicals) and warning type-i.e., the presence ("relative harm warning") or absence ("standard warning") of a relative harm (RH) statement in the warning label ("e-cigarettes may cause harm to health but are less harmful than cigarettes"). Warning believability, informativeness, understandability and support were high across conditions and there were no significant differences by warning theme on e-cigarette harm perceptions or use intentions nor on nicotine (mis)perceptions. Perceived warning effectiveness for discouraging youth initiation was higher for the "brain" and "chemicals" warnings compared to the addiction warning. Warnings with the included RH statement were perceived as less believable and credible and were less frequently correctly recalled. Research should continue to investigate the impact of different e-cigarette warning themes and formats with priority audiences.

Cigarette use and smoking beliefs among older Americans: findings from a nationally representative survey

Background: Between 2005 and 2015, the prevalence of smoking among US adults has decreased for all age subgroups, except those aged 65 and older. Aim: In order to identify potential correlates of smoking behaviors in older adults, this research examined associations between age, smoking beliefs, and quitline utilization. Methods: Self-reported, nationally representative data from the Health Information National Trends Survey 2015 cycle (HINTS-FDA) were used (n = 3738). Multivariable logistic regression analyses examined associations between sociodemographic characteristics and beliefs about smoking behaviors. All analyses were conducted with jackknife estimation using sampling weights. Results: Among all survey respondents, 10.5% of those aged 65+ were current smokers (smoked 100 lifetime cigarettes and currently smoked every day or some days). These older adults, compared to those aged 18-29 years, had significantly higher odds of agreeing that smoking behavior is something one can do little to change (AOR = 1.89, 95% CI =1.08, 3.28) and agreeing that nicotine is the substance that causes cancer (AOR = 3.93, 95% CI = 2.17, 7.12). Post hoc analyses compared midlife adults (ages 50-64) with older adults (ages 65+), and indicated older adults had lower odds of having used a quitline/smoking cessation website (AOR = 0.36, 95% CI = 0.14, 0.94, p = 0.04) compared to their midlife peers. Discussion: US adults aged 65 and older hold erroneous beliefs about cigarette smoking behaviors and are less likely to utilize quitline supports. This may be contributing to the stagnant smoking rates among older adults. Smoking cessation efforts targeting older adult Americans are critical in order to stem tobacco use among all Americans.

Extending Efforts to Move Cigarette and e-Cigarette Beliefs: Message Exposure and Belief Structures

This study examines message exposure and belief structures in the context of tobacco prevention and education efforts. Though it is imperative that researchers identify and test messaging strategies that move beliefs in the desired direction, these efforts must take care to consider the existing belief structures of the target audience. A pretest-posttest design was employed in order to extend an existing tobacco-free initiative. The study examined how participants structured their beliefs about tobacco and the initiative at the first time point (T1: N = 404) and tested the impact of persuasive messages at a second time point (T2: N = 192). The findings indicated that while one message produced change in a targeted norms-oriented belief, a constellation of messages hold promise for modifying a broader belief structure. The results are discussed in terms of their implications for message design and tobacco-free initiatives.

Nicotine and addiction beliefs and perceptions among the US-born and foreign-born populations

Little is known about nicotine and addiction beliefs held by those who are foreign-born in the US and how these beliefs are associated with acculturation and race/ethnicity. This study attempts to address these research gaps. Data were analyzed from two cycles of the Health Information National Trends Survey, HINTS-FDA 2015 (n = 3738) and HINTS-FDA 2017 (n = 1736). HINTS-FDA is a tobacco-focused, cross-sectional, nationally representative survey of US non-institutionalized civilian adults aged 18 years or older. We first assessed associations between foreign-born status and beliefs about nicotine and addiction using weighted chi-square analyses. Then, using only the foreign-born sample, we examined the associations of nicotine and addiction beliefs with race/ethnicity and acculturation (i.e., English proficiency and U.S. tenure) using weighted multiple linear regression. Results showed that, compared to US-born respondents, foreign-born respondents were more likely to be concerned with being addicted to nicotine and to believe that low nicotine cigarettes would have much lower lung cancer risk than a typical cigarette. Among the foreign-born, NH-Black and Hispanic respondents were more likely to see low nicotine cigarettes as harmful and addictive compared to NH-White respondents. The relationship between acculturation and nicotine beliefs was complex with lower acculturation associated with elevated misperceived risk of nicotine and also ratings of addictiveness. Further research among key subpopulations may inform communication, education and dissemination strategies, especially among vulnerable populations.

Validation of mobile phone text messages for nicotine and tobacco risk communication among college students: A content analysis

INTRODUCTION

In the United States, young adults have the highest prevalence of tobacco use. The dissemination of mobile phone text messages is a growing strategy for tobacco risk communication among young adults. However, little has been done concerning the design and validation of such text messages. The Texas Tobacco Center of Regulatory Science (Texas-TCORS) has developed a library of messages based on framing (gain- or loss-framed), depth (simple or complex) and appeal (emotional or rational). This study validated the library based on depth and appeal, identified text messages that may need improvement, and explored new themes.

METHODS

The library formed the study sample (N=976 messages). The Linguistic Inquiry and Word Count (LIWC) software of 2015 was used to code for word count, word length and frequency of emotional and cognitive words. Analyses of variance, logistic regression and scatter plots were conducted for validation.

RESULTS

In all, 874 messages agreed with LIWC-coding. Several messages did not agree with LIWC. Ten messages designed to be complex indicated simplicity, while 51 messages designed to be rational exhibited no cognitive words. New relevant themes were identified, such as health (e.g. ‘diagnosis’, ‘cancer’), death (e.g. ‘dead’, ‘lethal’) and social connotations (e.g. ‘parents’, ‘friends’).

CONCLUSIONS

Nicotine and tobacco researchers can safely use, for young adults, messages from the Texas-TCORS library to convey information in the intended style. Future work may expand upon the new themes. Findings will be utilized to develop new campaigns, so that risks of nicotine and tobacco products can be widely disseminated.

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.