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

Believability of messaging concerning a hypothetical product standard to lower a constituent in cigarettes or smokeless tobacco among U.S. Adults who use tobacco

The U.S. Food and Drug Administration (FDA) has regulatory authority to implement tobacco product standards to reduce harmful and potentially harmful constituents (HPHCs). This study examines people who use tobacco products' awareness of FDA's tobacco regulatory authority, knowledge of HPHCs, and belief in hypothetical tobacco product standard statements. We recruited adults who reported currently using tobacco (N = 1,592) from the National Panel of Tobacco Consumer Studies and randomized them to one of four conditions. Participants viewed a stimulus which consisted of a statement about a hypothetical product standard that would reduce the level of a chemical in cigarettes or smokeless tobacco (ST) and reduce cases of cancer or heart attack and stroke. A small majority of participants correctly believed that FDA regulates tobacco; however, the percentage of participants who recognized HPHCs varied widely depending upon the chemical. People who currently use ST found chemical and health statements more believable than people who did not currently use ST. Participants found it more believable that cigarettes, not ST, could be made with fewer harm-causing chemicals, and their belief in the chemical and health statements did not differ based on the health outcome specified in the hypothetical product standard statement.

Eliminating children's tobacco smoke exposure: a pathway to bioverified abstinence among low-income maternal smokers in the Babies Living Safe and Smokefree (BLiSS) trial

BACKGROUND

Identifying behavioral pathways to smoking cessation in high-risk populations, such as low-income maternal smokers, could reduce tobacco disparities. The previous "BLiSS" multilevel intervention trial demonstrated efficacy of the BLiSS intervention in facilitating low-income maternal smokers' bioverified abstinence. This present study examined four putative pathways measured at 3-month end of treatment (Time 2) that could account for the observed intervention effect on smoking abstinence through 12 months (Time 2 - Time 3).

METHODS

Nutritionists in community clinics delivering safety net nutrition promotion programs across Philadelphia, Pennsylvania, USA, were trained by trial principal investigators to deliver a brief tobacco intervention informed by the American Academy of Pediatrics best practice guidelines ("Ask, Advise, Refer [AAR]"). After referral, 396 eligible participants were randomized to either a multimodal behavioral intervention (AAR + MBI) or a parallel attention control (AAR + control). Random effects regression analysis tested mediation.

RESULTS

Elimination of children's tobacco smoke exposure (TSE) at Time 2 was the only significant mediator of longitudinal smoking abstinence through Time 3. AAR + MBI mothers were more likely to eliminate their children's TSE by Time 2 (OR = 2.11, 95%CI 1.30, 3.42), which was significantly associated with Time 3 abstinence (OR = 6.72, CI 2.28, 19.80). Modeling showed a significant total effect of AAR + MBI on abstinence (OR = 6.21, CI 1.86, 20.71), a direct effect of AAR + MBI on abstinence (OR = 4.80, CI 1.45, 15.94) and an indirect effect through TSE elimination (OR = 1.29, CI 1.06, 1.57).

CONCLUSIONS

Integrating smoking cessation interventions with counseling prior to the quit attempt that is designed to facilitate adoption of smokefree home policies and efforts to eliminate children's TSE could enhance the likelihood of long-term abstinence in populations of smokers with elevated challenges quitting smoking.

Awareness of and reactions to health and environmental harms of red meat among parents in the United States

OBJECTIVE

Evidence of the health and environmental harms of red meat is growing, yet little is known about which harms may be most impactful to include in meat reduction messages. This study examined which harms consumers are most aware of and which most discourage them from wanting to eat red meat.

DESIGN

Within-subjects randomised experiment. Participants responded to questions about their awareness of, and perceived discouragement in response to, eight health and eight environmental harms of red meat presented in random order. Discouragement was assessed on a 1-to-5 Likert-type scale.

SETTING

Online survey.

PARTICIPANTS

544 US parents.

RESULTS

A minority of participants reported awareness that red meat contributes to health harms (ranging from 8 % awareness for prostate cancer to 28 % for heart disease) or environmental harms (ranging from 13 % for water shortages and deforestation to 22 % for climate change). Among specific harms, heart disease elicited the most discouragement (mean = 2·82 out of 5), followed by early death (mean = 2·79) and plants and animals going extinct (mean = 2·75), though most harms elicited similar discouragement (range of means, 2·60-2·82). In multivariable analyses, participants who were younger, identified as Black, identified as politically liberal, had higher general perceptions that red meat is bad for health and had higher usual red meat consumption reported being more discouraged from wanting to eat red meat in response to health and environmental harms (all P < 0·05).

CONCLUSIONS

Messages about a variety of health and environmental harms of red meat could inform consumers and motivate reductions in red meat consumption.

Message perceptions and effects perceptions as proxies for behavioral impact in the context of anti-smoking messages

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In the context of anti-smoking messages, effects perceptions (perceived behavioral impact) mediated message impact on quit intentions and six quitting and related behaviors while message perceptions (persuasive potential) did not.

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The sizes of indirect effects involving effects perceptions ranged from small to medium.

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These findings provide support for the diagnostic value of effects perceptions in testing messages for behavior change in the context of tobacco use and, possibly, other risky health behaviors.

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The use of effects perceptions in formative research may increase the efficiency with which behavior change interventions can be developed and optimized under resource constraints.

Researchers commonly use message perceptions (persuasive potential) or effects perceptions (perceived behavioral impact) in formative research to select tobacco risk messages. We sought to identify whether message perceptions or effects perceptions are more useful as proxies for the behavioral impact of tobacco risk messages. In a three-week trial, 703 U.S. adult smokers (ages ≥ 21) were randomly assigned to receive brief messages on their cigarette packs about toxic chemicals in cigarette smoke (chemical messages) or control messages about properly disposing of cigarette litter. The final follow-up survey assessed message perceptions, effects perceptions, quit intentions, and six behavioral outcomes. We conducted multiple mediation analysis in a structural equation modeling framework to test the indirect effects of messages by way of message perceptions and effects perceptions. Message perceptions did not independently mediate the impact of chemical messages on any of the outcomes (7 p-values ≥ 0.01). In contrast, effects perceptions mediated the impact of chemical messages on avoiding the messages, seeking chemical information, intentions to quit smoking, butting out a cigarette, forgoing a cigarette, and making a quit attempt (6 p-values ≤ 0.001). No mediation was present for social interactions about the message (p-value = 0.72). The effect sizes for these mediated effects were small to medium. Thus, effects perceptions, but not message perceptions, were a proxy for risk messages’ impact on quit intentions and six quitting and related behaviors. These findings point to the diagnostic value of effects perceptions in formative research on tobacco risk messages.

Experimental Test of the Educational Impact of the Newly Proposed FDA Graphic Cigarette Warnings Among U.S. Adults

BACKGROUND

In August 2019, the U.S. Food and Drug Administration proposed a set of 13 new graphic warnings for cigarette packaging and advertisements.

PURPOSE

We evaluated these warnings relative to text-only equivalents for their ability to educate the public regarding harms of smoking and influence outcomes associated with quitting.

METHODS

In an experimental within-subjects design, U.S. adult nonsmokers, smokers, and dual smoker/electronic cigarette (e-cigarette) users (N = 412) recruited from an online internet platform evaluated the newly proposed graphic warnings and corresponding text-only warnings on understandability, perceived new knowledge, worry elicited about the content of the warning, discouragement from smoking, and encouragement to use e-cigarettes.

RESULTS

Graphic warnings were generally rated as providing better understanding, more new knowledge, eliciting more worry about harms of smoking, and providing more discouragement from smoking relative to text-only warnings.

CONCLUSIONS

The newly proposed graphic warnings could influence important responses to warnings associated with motivation to reduce smoking.

Effect of Cigarette Constituent Messages With Engagement Text on Intention to Quit Smoking Among Adults Who Smoke Cigarettes: A Randomized Clinical Trial

IMPORTANCE

The US Food and Drug Administration (FDA) is required to communicate the risks of tobacco constituents to the public. Few studies have addressed how FDA media campaigns can effectively communicate about cigarette smoke constituents.

OBJECTIVE

To examine whether messages about cigarette smoke constituents are effective in reducing smoking intentions and behaviors among adults who smoke.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial enrolled participants who were aged between 18 and 65 years, were English speakers, were living in the United States, and who smoked at least 100 cigarettes during their lifetime and now smoked every day or some days. Participants received daily messages via email for 15 days. Participants were randomized to 1 of 2 message conditions or a control group and reported their previous-day smoking behaviors daily. Follow-up surveys were conducted on days 16 and 32. Data were collected from June 2017 to April 2018 and analyzed from April to September 2018.

INTERVENTIONS

The 3 groups were (1) constituent plus engagement messages (eg, "Cigarette smoke contains arsenic. This causes heart damage.") that included the FDA as the source and engagement text (eg, "Within 3 months of quitting, your heart and lungs work better. Ready to be tobacco free? You can quit. For free nicotine replacement, call 1-800-QUIT-NOW"); (2) constituent-only messages that did not list the FDA as the source or include engagement text; and (3) a control condition with messages about littering cigarette butts.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in quit intentions (range, 1-4, with higher scores indicating stronger intentions) from pretest to day 16. Secondary outcome measures included daily smoking behaviors and quit attempts.

RESULTS

A total of 789 participants (mean [SD] age, 43.4 [12.9] years; 483 [61.2%] women; 578 [73.3%] White; 717 [90.9%] non-Hispanic) were included in the study. The mean (SD) quit intention score was 2.5 (0.9) at pretest. Mean (SE) change in quit intention score from pretest to day 16 was 0.19 (0.07) points higher in the constituent plus engagement condition than in the control condition (P = .005) and 0.23 (0.07) points higher in the constituent-only condition compared with the control condition (P = .001). Participant reports of cigarettes smoked, forgone, and butted out were similar across study conditions at baseline and did not differ significantly at days 16 and 32 across study conditions. Viewing more messages was associated with an estimated decrease of 0.15 (SE, 0.01) cigarettes smoked per day per message viewed overall across conditions.

CONCLUSIONS AND RELEVANCE

To our knowledge, this is the first longitudinal test of cigarette constituent campaign messages in a national sample of adults who currently smoke. Messages about cigarette smoke constituents, with or without engagement text and source information, increased participants' intentions to quit, lending support to FDA efforts to educate consumers about such constituents.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03339206.

Can the Public Be Educated About Constituents in Smokeless Tobacco? A Three-Wave Randomized Controlled Trial

INTRODUCTION

The U.S. Food and Drug Administration (FDA) is required by law to inform the public about levels of harmful and potentially harmful tobacco constituents in a format that is "understandable and not misleading to a lay person." Our study addresses a critical gap in research on communicating such information for smokeless tobacco (SLT) products.

METHODS

The design included random assignment to one of the experimental (online interactive) conditions differing in presentation format or a control condition (receiving no information). Experimental respondents viewed information on levels and health risks of 5 harmful constituents in up to 79 products. Outcome measures included knowledge of health risks of constituents, perception of constituent variability in SLT products, disease risk ratings, self-reported SLT use, and side-by-side product comparisons. The sample of 333 SLT users, 535 cigarette smokers, and 663 nontobacco users participated at baseline, time of intervention, and 6 weeks postintervention.

RESULTS

Presentation formats showed few systematic differences so were combined in analyses. Experimental condition respondents increased their knowledge about constituent health effects and their perceptions of constituent variability in SLT products, from baseline to postintervention, and relative to the control condition. Changes in respondents' ratings of disease risk and their estimates of constituent exposure from specific products were observed, but not in self-reported SLT use.

CONCLUSIONS

Interactive online graphic and numeric presentation formats can be efficient in increasing people's knowledge of health effects and perceived variation of constituents in SLT products. Further research on longer-term behavioral assessment, and usefulness of this approach for regulatory agencies, is needed.

IMPLICATIONS

Research on communicating the information about harmful constituents in SLT products to lay persons is critically lacking. This study proposes novel formats for effective communication about the levels and the health effects of SLT constituents to multiple user groups. The lack of misperceptions among study participants that some tobacco products are safe suggests that such formats can potentially be used for public display of SLT constituent data by the FDA and regulatory agencies in other countries.

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.

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.

Research on Youth and Young Adult Tobacco Use, 2013-2018, From the Food and Drug Administration-National Institutes of Health Tobacco Centers of Regulatory Science

The Tobacco Regulatory Science Program is a collaborative research effort between the National Institutes of Health (NIH) and the Food and Drug Administration (FDA). In 2013, the NIH funded 14 Tobacco Centers of Regulatory Science (TCORS), which serve as partners in establishing research, training, and professional development programs to guide FDA. Each of the fourteen TCORS, and two other NIH-funded research programs, the Center for the Evaluation of Nicotine in Cigarettes (CENIC) and the Consortium on Methods Evaluating Tobacco (COMET), pursued specific research themes relevant to FDA's priorities. A key mandate for FDA is to reduce tobacco use among young people. This article is a review of the peer-reviewed research, including published and in-press manuscripts, from the TCORS, CENIC, and COMET, which provides specific data or other findings on youth (ages 10-18 years) and/or young adults (ages 18-34 years), from 2013 to 2018. Citations of all TCORS, CENIC, and COMET articles from September 2013 to December 2017 were collected by the TCORS coordinating center, the Center for Evaluation and Coordination of Training and Research. Additional citations up to April 30, 2018 were requested from the principal investigators. A scoring rubric was developed and implemented to assess study type, primary theme, and FDA priority area addressed by each article. The major subareas and findings from each priority area are presented. There were 766 articles in total, with 258 (34%) focusing on youth and/or young adults. Findings relevant to FDA from this review concern impact analysis, toxicity, health effects, addiction, marketing influences, communications, and behavior.

IMPLICATIONS

The Tobacco Centers of Regulatory Science, CENIC, and COMET have had a high output of scientific articles since 2013. These Centers are unique in that the FDA supports science specifically to guide future regulatory actions. The 258 articles that have focused on youth and/or young adults are providing data for regulatory actions by the FDA related to the key priority areas such as the addictiveness of non-cigarette products, the effects of exposure to electronic cigarette marketing on initiation and cessation, and the impact of flavored products on youth and young adult tobacco use. Future regulations to reduce tobacco use will be guided by the cumulative evidence. These Centers are one innovative mechanism to promote important outcomes to advance tobacco regulatory science.

An Eye Tracking Study of Anti-Smoking Messages on Toxic Chemicals in Cigarettes

The US Food and Drug Administration is tasked with communicating information to the public about the harmful chemicals in cigarette smoke. Our study used eye tracking method to test the effectiveness of messages about the harmful chemicals in cigarettes smoke among adult smokers. A sample size of 211 current cigarette smokers viewed four communication messages that included: Health effects of a chemical in cigarette smoke and an image depicting the health effect. The messages focused on arsenic, formaldehyde, uranium, and general health. Eye tracking recorded the length of time participants viewed the text and the image. After each message, the participants were asked about the messages' effectiveness in changing attitudes towards smoking. We analyzed the data using multilevel modeling, and of the 211 smokers, 59.7% were female, 36.5% were Black, and 21.3% had a high school degree or less. Compared to the general message, the messages about formaldehyde and uranium were more discouraging to smoking (p < 0.05). Messages about formaldehyde were more believable and made participants want to quit more than the general messages. Increasing message dose was significantly associated with discouraging participants from smoking and made participants want to quit (p < 0.05). Our findings suggest that anti-smoking messages, containing chemical information, can successfully increase negative attitudes toward smoking cigarettes and potentially encourage quitting.

Sugar-Sweetened Beverage Health Warnings and Purchases: A Randomized Controlled Trial

INTRODUCTION

Five U.S. states have proposed policies to require health warnings on sugar-sweetened beverages, but warnings' effects on actual purchase behavior remain uncertain. This study evaluated the impact of sugar-sweetened beverage health warnings on sugar-sweetened beverage purchases.

STUDY DESIGN

Participants completed one study visit to a life-sized replica of a convenience store in North Carolina. Participants chose six items (two beverages, two foods, and two household products). One item was randomly selected for them to purchase and take home. Participants also completed a questionnaire. Researchers collected data in 2018 and conducted analyses in 2019.

SETTING/PARTICIPANTS

Participants were a demographically diverse convenience sample of 400 adult sugar-sweetened beverage consumers (usual consumption ≥12 ounces/week).

INTERVENTION

Research staff randomly assigned participants to a health warning arm (sugar-sweetened beverages in the store displayed a front-of-package health warning) or a control arm (sugar-sweetened beverages displayed a control label).

MAIN OUTCOME MEASURES

The primary trial outcome was sugar-sweetened beverage calories purchased. Secondary outcomes included reactions to trial labels (e.g., negative emotions) and sugar-sweetened beverage perceptions and attitudes (e.g., healthfulness).

RESULTS

All 400 participants completed the trial and were included in analyses. Health warning arm participants were less likely to be Hispanic and to have overweight/obesity than control arm participants. In intent-to-treat analyses adjusting for Hispanic ethnicity and overweight/obesity, health warnings led to lower sugar-sweetened beverage purchases (adjusted difference, -31.4 calories; 95% CI= -57.9, -5.0). Unadjusted analyses yielded similar results (difference, -32.9 calories; 95% CI= -58.9, -7.0). Compared with the control label, sugar-sweetened beverage health warnings also led to higher intentions to limit sugar-sweetened beverage consumption and elicited more attention, negative emotions, thinking about the harms of sugar-sweetened beverage consumption, and anticipated social interactions. Trial arms did not differ on perceptions of sugar-sweetened beverages' added sugar content, healthfulness, appeal/coolness, or disease risk.

CONCLUSIONS

Brief exposure to health warnings reduced sugar-sweetened beverage purchases in this naturalistic RCT. Sugar-sweetened beverage health warning policies could discourage sugar-sweetened beverage consumption.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03511937.

UNC Perceived Message Effectiveness: Validation of a Brief Scale

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

"Organic," "Natural," and "Additive-Free" Cigarettes: Comparing the Effects of Advertising Claims and Disclaimers on Perceptions of Harm

INTRODUCTION

The US Tobacco Control Act restricts advertising or labeling that suggests one tobacco product is less harmful than another. We sought to examine how "organic," "natural," and "additive-free" advertising claims and corresponding disclaimers affect perceptions of cigarettes' harm.

METHODS

Participants were a national probability sample of adults in the United States (n = 1114, including 344 smokers). We conducted a 5 (claim) × 2 (disclaimer) between-subjects factorial experiment. Participants viewed a Natural American Spirit cigarettes ad claiming they were "organic," "natural," "additive-free," "light," or "regular;" and with or without a corresponding disclaimer. The outcome was perceived harm of the advertised cigarettes. Among smokers, we also assessed interest in switching within their current brand to cigarettes with this characteristic (eg, "additive-free").

RESULTS

Claims in the ad had a large effect on perceived harm (Cohen's d = 0.87, 95% CI = 0.47 to 1.29). Claims of cigarettes being "organic," "natural," or "additive-free" reduced perceived harm from the advertised cigarettes, as compared with "regular" and "light" claims. Disclaimers had a small effect, increasing perceived harm (d = 0.25, 95% CI = 0.08 to 0.41). The problematic claims also increased smokers' interest in switching. Disclaimers had no effect on smokers' interest in switching.

CONCLUSIONS

"Organic," "natural," and "additive-free" claims may mislead people into thinking that the advertised cigarettes are less harmful than other cigarettes. Disclaimers did not offset misperceptions of harm created by false claims. The US Food and Drug Administration should restrict the use of these misleading claims in tobacco advertising.

IMPLICATIONS

"Organic," "natural," and "additive-free" cigarette advertising claims decrease perceptions of harm among the public and increase interest in switching to such cigarettes among smokers. Disclaimers do not counteract the reduced perceptions of harm or increased interest in switching to these cigarettes. The US Food and Drug Administration should restrict the use of "organic," "natural," and "additive-free" claims in tobacco marketing.

How should sugar-sweetened beverage health warnings be designed? A randomized experiment

Health warnings are a promising strategy for reducing consumption of sugar-sweetened beverages (SSBs), but uncertainty remains about how to design warnings to maximize their impact. Warnings already implemented in Latin America use nutrient disclosures, while proposed U.S. warnings would describe the health effects of consuming SSBs. We sought to determine whether warning characteristics influence consumers' reactions to SSB health warnings. A national convenience sample of U.S. adults (n = 1360) completed an online survey in 2018. In a factorial design, we randomly assigned participants to view SSB health warnings that differed in: 1) inclusion of health effects ("Drinking beverages with added sugar contributes to obesity, diabetes, and tooth decay"); 2) inclusion of a nutrient disclosure ("High in added sugar"); 3) inclusion of the marker word "WARNING;" and 4) shape (octagon vs. rectangle). The primary outcome was perceived message effectiveness (PME, range 1-5). PME was higher for warnings that included health effects (average differential effect [ADE] = 0.63, p < 0.001) or nutrient disclosures (ADE = 0.32, p < 0.001) compared to warnings without this information. However, adding a nutrient disclosure to a warning that already included health effects did not lead to higher PME compared to warnings with health effects alone. The marker "WARNING" (ADE = 0.21) and the octagon shape (ADE = 0.08) also led to higher PME compared to warnings without these characteristics (ps < 0.001). The same pattern of results held for the secondary outcomes, fear and thinking about harms. SSB health warnings may have more impact if they describe health effects, use the marker "WARNING," and are octagon-shaped.

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

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

Do Smokers Recall Source or Quitline on Cigarette Constituent Messages?

OBJECTIVES

The Food and Drug Administration (FDA) is required under the Family Smoking Prevention and Tobacco Control Act to communicate the risks of tobacco use to the public. Little research exists about methods to communicate the constituents of tobacco in a media campaign. This research examines specific strategies to increase effectiveness of a media campaign for cigarette smoking adults about tobacco constituents by including engagement text about smoking cessation and FDA as the source of the campaign.

METHODS

In an eye tracking study of 211 current cigarette smokers, participants randomly viewed 4 cigarette constituent messages that varied engagement text for quitting (benefits of quitting and quitline number, presence, absence) and by FDA source (presence, absence). After the eye tracking session, participants were asked about recall of the national quitline number and the source of message.

RESULTS

Participants in conditions with engagement text were significantly more likely than those in the no engagement conditions to recall the national quitline number. Few participants saw or recalled the FDA source.

CONCLUSIONS

Engagement text for smoking cessation on constituent communication campaign messages significantly increases recall of the quitline, an important resource for smokers.

Effective Message Elements for Disclosures About Chemicals in Cigarette Smoke

Introduction

Cigarette smoke contains at least 93 chemicals or "constituents" that the Food and Drug Administration has identified as harmful and potentially harmful constituents to human health. Our study sought to identify which constituent disclosure message elements are most effective in discouraging people from smoking.

Methods

Three hundred eighty eight current smokers aged 18 and older completed an online survey in February 2015. We randomized participants to respond to one of two sets of 13 toxic products that contain cigarette constituents and 25 health effects associated with cigarette constituents.

Results

Products that elicited the most discouragement were those with lower chances of exposure (e.g., explosives), followed by products with possible exposure (e.g., rat poison), and products with a high likelihood of exposure (e.g., floor cleaner). Awareness of toxic products that constituents are found in (p < .001) and low exposure products (p < .001) were associated with higher discouragement. Health effects that people had heard are caused by cigarette smoke constituents elicited higher discouragement from smoking cigarettes (p < .001). Cancer was associated with higher discouragement relative to respiratory, cardiovascular, and reproductive health effects (all p < .001).

Conclusions

Cigarette smoke constituent messages may be more effective at discouraging smoking if they include information about carcinogenic health effects (e.g., mouth cancer and lung tumors) and low exposure toxic products (e.g., explosives and radioactive material) as message elements.

Implications

Our study identified health effects and toxic products, especially cancers and rarely encountered toxic products, that may discourage smoking when included in disclosure messages. By constructing messages that communicate the harms associated with tobacco use by contextualizing those harms in terms of specific constituents, tobacco education messaging efforts may be increasingly successful.

Increasing Effectiveness of Messages about Chemicals in Cigarette Smoke

OBJECTIVES

Federal law requires informing the public on toxic chemicals in cigarette smoke. We sought the public's advice about communicating information about these chemicals.

METHODS

Adolescents, young adults, and adults (N = 59), including smokers and non-smokers, participated in 9 focus groups that discussed inclusion of messages about toxic chemicals on cigarette packs, in media campaigns, and on a website. We transcribed, coded, and analyzed focus group audio-recordings.

RESULTS

Participants had 3 suggestions for message content to increase the impact of messages about cigarette smoke chemicals. First, they wanted to see messages rotated more frequently to increase message novelty. Second, they recommended using stories and pictures to help connect people to the abstract idea of chemicals in smoke. Third, they cautioned against making messages that might seem overblown and could appeal to the rebellious nature of adolescents. Some participants mentioned that chemical information on a website might discourage people from smoking; others mentioned that people might use it to choose which brand to smoke.

CONCLUSIONS

Legislation provides the impetus to design new chemical disclosure messages for cigarette packs and other media. Our findings can help increase the impact of these messages.

Cigarette pack messages about toxic chemicals: a randomised clinical trial

Background

The USA can require tobacco companies to disclose information about harmful and potentially harmful chemicals in cigarette smoke, but the impact of these messages is uncertain. We sought to assess the effect of placing messages about toxic chemicals on smokers’ cigarette packs.

Methods

Participants were 719 adult cigarette smokers from California, USA, recruited from September 2016 through March 2017. We randomly assigned smokers to receive either factual messages about chemicals in cigarette smoke and their health harms (intervention) or messages about not littering cigarette butts (control) on the side of their cigarette packs for 3 weeks. The primary trial outcome was intention to quit smoking.

Results

In intent-to-treat analyses, smokers whose packs had chemical messages did not have higher intentions to quit smoking at the end of the trial than those whose packs had control messages (P=0.56). Compared with control messages, chemical messages led to higher awareness of the chemicals (28% vs 15%, P<0.001) and health harms (60% vs 52%, P=0.02) featured in the messages. In addition, chemical messages led to greater negative affect, thinking about the chemicals in cigarettes and the harms of smoking, conversations about the messages and forgoing a cigarette (all P<0.05).

Discussion

Chemical messages on cigarette packs did not lead to higher intentions to quit among smokers in our trial. However, chemical messages informed smokers of chemicals in cigarettes and harms of smoking, which directly supports their implementation and would be critical to defending the messages against cigarette company legal challenges.

Trial registration number

NCT02785484.

Optimizing Tailored Communications for Health Risk Assessment: A Randomized Factorial Experiment of the Effects of Expectancy Priming, Autonomy Support, and Exemplification

Background

Health risk assessments with tailored feedback plus health education have been shown to be effective for promoting health behavior change. However, there is limited evidence to guide the development and delivery of online automated tailored feedback.

Objective

The goal of this study was to optimize tailored feedback messages for an online health risk assessment to promote enhanced user engagement, self-efficacy, and behavioral intentions for engaging in healthy behaviors. We examined the effects of three theory-based message factors used in developing tailored feedback messages on levels of engagement, self-efficacy, and behavioral intentions.

Methods

We conducted a randomized factorial experiment to test three different components of tailored feedback messages: tailored expectancy priming, autonomy support, and use of an exemplar. Individuals (N=1945) were recruited via Amazon Mechanical Turk and randomly assigned to one of eight different experimental conditions within one of four behavioral assessment and feedback modules (tobacco use, physical activity [PA], eating habits, and weight). Participants reported self-efficacy and behavioral intentions pre- and postcompletion of an online health behavior assessment with tailored feedback. Engagement and message perceptions were assessed at follow-up.

Results

For the tobacco module, there was a significant main effect of the exemplar factor (P=.04); participants who received exemplar messages (mean 3.31, SE 0.060) rated their self-efficacy to quit tobacco higher than those who did not receive exemplar messages (mean 3.14, SE 0.057). There was a three-way interaction between the effect of message conditions on self-efficacy to quit tobacco (P=.02), such that messages with tailored priming and an exemplar had the greatest impact on self-efficacy to quit tobacco. Across PA, eating habits, and weight modules, there was a three-way interaction among conditions on self-efficacy (P=.048). The highest self-efficacy scores were reported among those who were in the standard priming condition and received both autonomy supportive and exemplar messages. In the PA module, autonomy supportive messages had a stronger effect on self-efficacy for PA in the standard priming condition. For PA, eating habits, and weight-related behaviors, the main effect of exemplar messages on behavioral intentions was in the hypothesized direction but did not reach statistical significance (P=.08). When comparing the main effects of different message conditions, there were no differences in engagement and message perceptions.

Conclusions

Findings suggest that tailored feedback messages that use exemplars helped improve self-efficacy related to tobacco cessation, PA, eating habits, and weight control. Combining standard priming and autonomy supportive message components shows potential for optimizing tailored feedback for tobacco cessation and PA behaviors.

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.