Momentary effects of exposure to prosmoking media on college students' future smoking risk

Ecological Momentary Assessment of Alcohol Marketing Exposure, Alcohol Use, and Purchases Among University Students: Prospective Cohort Study

BACKGROUND

The relationships between alcohol marketing exposure, alcohol use, and purchase have been widely studied. However, prospective studies examining the causal relationships in real-world settings using mobile health tools are limited.

OBJECTIVE

We used ecological momentary assessment (EMA) to examine both the within-person- and between-person-level effects of alcohol marketing exposure on any alcohol use, amount of alcohol use, any alcohol purchase, and frequency of alcohol purchase among university students.

METHODS

From January to June 2020, we conducted a prospective cohort study via EMA among university students in Hong Kong who reported current drinking. Over 14 consecutive days, each participant completed 5 fixed-interval, signal-contingent EMAs daily via a smartphone app. Each EMA asked about the number and types of alcohol marketing exposures, the amount and types of alcohol used, and whether any alcohol was purchased, all within the past 3 hours. We used 2-part models, including multilevel logistic regressions and multilevel gamma regressions, to examine if the number of alcohol marketing exposure was associated with subsequent alcohol use and alcohol purchase.

RESULTS

A total of 49 students participated, with 33% (16/49) being male. The mean age was 22.6 (SD 2.6) years. They completed 2360 EMAs (completion rate: 2360/3430, 68.8%). Participants reported exposure to alcohol marketing in 5.9% (140/2360), alcohol use in 6.1% (145/2360), and alcohol purchase in 2.4% (56/2360) of all the EMAs. At the between-person level, exposure to more alcohol marketing predicted a higher likelihood of alcohol use (adjusted odd ratio [AOR]=3.51, 95% CI 1.29-9.54) and a higher likelihood of alcohol purchase (AOR=4.59, 95% CI 1.46-14.49) the following day. Exposure to more alcohol marketing did not increase the amount of alcohol use or frequency of alcohol purchases the following day in participants who used or purchased alcohol. At the within-person level, exposure to more alcohol marketing was not associated with a higher likelihood of alcohol use, amount of alcohol use, higher likelihood of alcohol purchase, or frequency of alcohol purchases the following day (all Ps>.05). Each additional exposure to alcohol marketing within 1 week predicted an increase of 0.85 alcoholic drinks consumed in the following week (adjusted B=0.85, 95% CI 0.09-1.61). On days of reporting alcohol use, the 3 measures for alcohol marketing receptivity were not associated with more alcohol use or purchase (all Ps>.05).

CONCLUSIONS

By using EMA, we provided the first evidence for the effect of alcohol marketing exposure on initiating alcohol use and purchase in current-drinking university students. Our findings provide evidence of the regulation of alcohol marketing for the reduction of alcohol use and purchase among young adults.

Cannabis advertising impacts on youth cannabis use intentions following recreational legalization in Canada: An Ecological Momentary Assessment (EMA) study

OBJECTIVE

In 2018, Canada's Cannabis Act legalized adult recreational cannabis use and limited cannabis product advertising to adults. Cannabis product advertising to youth remains illegal. The extent to which adult-targeted, or illicit youth-targeted cannabis advertisements is reaching and impacting Canadian youth is unknown. We used Ecological Momentary Assessment (EMA) to describe how often and how much exposures to cannabis advertising influence Canadian youths' real-world, real-time intentions to use cannabis.

METHODS

120 Ontario, Canada youths ages 14-18, took photos of cannabis advertising that they encountered in their natural environments over a period of nine consecutive days. Following each exposure and twice daily device-issued random prompts, they also rated their intentions to use cannabis.

RESULTS

Many participating youth (n = 85; 70.83 %) reported at least one cannabis advertising exposure during the study (range 1-30, M = 4.02). Exposures occurred through a range of advertising channels (e.g., internet ads, billboards). Multilevel modeling showed that youth advertising exposure increased cannabis use intentions in vivo (β = 0.06,SE = 0.03;t = 1.98;p =.04;n = 1,348).

CONCLUSION

Data from this study shows that cannabis advertisements are regularly reaching Canadian youth and increasing their intentions to use cannabis. This suggests that current Canadian prohibitions on cannabis advertising to youth are ineffective and/or ineffectively enforced, and that the Canadian government needs additional or enhanced prohibitions on cannabis promotion to protect youth from harms associated with increased advertisement exposure, such as increased cannabis use.

Tobacco advertising exposure and product use among young adults: An ecological momentary assessment approach

INTRODUCTION

Tobacco-related content is prevalent on social media, yet many methods of measuring exposure are inadequate due to the personalized nature of online marketing. The purpose of this paper is to examine the association between exposure to pro-tobacco messages (both industry-sponsored and user-generated) and the use of tobacco products, as reported via ecological momentary assessment (EMA).

METHODS

Young adults (n = 175) were instructed to record all sightings of marketing (both in-person and online) related to tobacco for 28 days. Tobacco product use and recall of message encounters were assessed daily using app-initiated EMA.

RESULTS

Participants who reported exposure to tobacco messages were significantly more likely to report using tobacco, adjusting for gender, age, race/ethnicity, baseline use of any tobacco product, and having friends who use tobacco and e-cigarettes (p <.001). For each industry-sponsored message viewed, the odds of using tobacco or e-cigarettes in a given day increased by a factor of 1.77 (95 % CI = 1.41, 2.23). For each user-generated message viewed, the odds of using tobacco or e-cigarettes in a given day increased by a factor of 1.52 (95 % CI = 1.27, 1.83).

DISCUSSION

To our knowledge, this is the first study to specifically examine the association between exposure to user-generated messages and daily tobacco use. The findings suggests that there is a unique element to user-generated messages that distinguishes them from both traditional marketing and from simple peer influence.

Real-Time Context of Tobacco Marketing Exposure and Community Vulnerability-An Ecological Momentary Assessment Among Young Adults

BACKGROUND

Exposure to tobacco product marketing increases tobacco use among young adults, especially those from vulnerable communities (VCs).

PURPOSE

This study examined real-time tobacco marketing exposure among young adults from vulnerable and non-vulnerable communities using Ecological Momentary Assessment (EMA).

METHODS

This study used EMA data to assess context (e.g., location and activity) of tobacco marketing exposure using four text-messaging surveys per day over 2 weeks. Young adult non-current tobacco users living in Washington, D.C. (n = 146; ages 18-24) recorded 5,285 surveys, including 20 participants (13.2%) from VCs with high proportions of lower income and racial/ethnic minorities, and high smoking rates. Unadjusted and adjusted multilevel logistic regressions were used to assess the associations between exposure to any and flavored tobacco marketing, VC residence, and real-time context.

RESULTS

Fifty-nine participants (40.4%) reported at least one tobacco marketing exposure and recorded 94 exposure moments. In adjusted models, odds of exposure were higher among VC residents (AOR = 2.6, 95% CI = 1.2-5.4), in the presence of anyone using tobacco versus no use (AOR = 4.0, 95% CI = 2.4-6.7), at store/retail (AOR = 17.0, 95% CI = 6.4-44.8), or outside/in transit (AOR = 4.1, 95% CI = 2.1-7.8) versus at home. VC residence (AOR = 7.2, 95% CI = 2.3-22.2) was the strongest predictor of flavored tobacco marketing exposure among all covariates examined.

CONCLUSIONS

Young adults are predominantly exposed to tobacco marketing in their daily lives through retail advertisements. Young adults from VCs are at increased risks of seeing any tobacco and especially flavored tobacco marketing. Policies that curtail tobacco retailer density and advertisement displays may reduce overall and differential tobacco marketing exposure.

Adolescent exposure to cannabis marketing following recreational cannabis legalization in Canada: A pilot study using ecological momentary assessment

Objective

The goal of this pilot study was to assess the feasibility of a 9-day, smartphone-based ecological momentary assessment (EMA) protocol for tracking the frequency of Canadian adolescents' exposures to cannabis marketing, their reactions to such exposures, and the context in which exposures occur in the real-world and in real-time.

Method

Participants were n = 18 adolescents between the ages of 14 and 18 years of age. They used an EMA application to capture and describe cannabis marketing exposures through photographs and brief questionnaires assessing marketing channel and context. Participants also rated their reactions to each exposure in real-time.

Results

Results showed that participants were generally compliant with the protocol. Participants recorded 40 total exposures to cannabis marketing, representing an average of 2.2 (SD 2.3) exposures per participant during the 9-day study. Exposures tended to occur in the afternoon (45.0%) or evening (37.5%), and while participants were at home (70%) and alone (52.5%). Most exposures occurred through promotion by public figures (27.5%) or explicitly marked internet ads (27.5%).

Conclusion

This is the first study to demonstrate the feasibility and utility of EMA to capture adolescent exposures to cannabis marketing as it occurs in participants' natural environments. Our research offers an early look at the predictable wave of cannabis advertising targeting youth and a promising approach for studying its impacts in a post-legalization context, as well as a strategy for assessing policies, such as advertising restrictions, intending to mitigate the harms of early cannabis use among youth.

Smoking in Young Adults: A Study of 4-Year Smoking Behavior Patterns and Residential Presence of Features Facilitating Smoking Using Data From the Interdisciplinary Study of Inequalities in Smoking Cohort

INTRODUCTION

Young adults have the highest prevalence of smoking among all age groups in most industrialized countries and exhibit great variability in smoking behavior. Differences in associations between features in residential environments and smoking initiation, prevalence, and cessation have been extensively examined in the literature. Nonetheless, in many cases, findings remain inconsistent. This paper proposes that a potential driver of these inconsistencies is an almost exclusive focus on point-specific smoking outcomes, without consideration for the different behavior patterns that this age group may experience over time.

AIMS AND METHODS

Based on data from the Interdisciplinary Study of Inequalities in Smoking cohort of 18- to 25-year-old Montreal residents (n = 1025), we examined associations between 4-year smoking patterns measured at three timepoints and proximal presence/density of tobacco retail outlets and presence of smoker accommodation facilities in Montreal, Canada. Associations were tested using two-level multinomial and logistic models.

RESULTS

In fully adjusted models, compared to never-smokers, residents of areas with a higher density of tobacco retail were more likely to (1) be characterized as established smokers, (2) have experienced repeated changes in smoking status (being "switchers") during the 4-year study period, and (3) be former smokers.

CONCLUSIONS

From a conceptual standpoint, these findings highlight the importance of acknowledging and examining smoking behavior patterns among young adults. Furthermore, specific pattern-feature associations may point to unique mechanisms by which features could influence smoking behavior patterns. These findings require replication and extension, including testing hypotheses regarding tobacco retail density's role in sustaining smoking and in influencing changes in smoking status.

IMPLICATIONS

Results from this study highlight the importance of describing and examining different young adult smoking behavior patterns and how they may be influenced by residential environment features such as the density of tobacco retail. Findings suggest that young adults residing in areas with a higher density of tobacco retailers are more likely to have experienced repeated changes in smoking status and to be established smokers. Further research in this area is needed to advance knowledge of the putative mechanisms by which residential features may influence smoking behavior patterns and to ultimately orient policy and interventions seeking to curb smoking at the local level.

Associations of Tobacco Advertising Appeal With Intentions to Use Alternative Tobacco Products Among Young Tobacco Users Experiencing Homelessness

PURPOSE

Virtually nothing is known about the potential effects of tobacco advertising on tobacco use among youth experiencing homelessness, a vulnerable population with high tobacco use rates. This study examines associations between the appeal of advertising for 5 classes of tobacco product (electronic cigarettes, hookah, cigars, cigarillos, and smokeless tobacco) and future intentions to use those products again among homeless youth who had indicated any level of lifetime use.

DESIGN

A cross-sectional design was used.

SETTING

Settings were 25 service and street sites in Los Angeles County.

PARTICIPANTS

A probability sample of 469 young tobacco users experiencing homelessness (mean age = 22; 71% male; 29% non-Hispanic White) was recruited.

MEASURES

Assessments included product-specific tobacco advertising appeal and future intentions to use the product again, as well as a range of covariate controls (eg, demographics, homelessness severity, current tobacco use, general advertising exposure).

ANALYSIS

Linear regression tested for associations between the appeal of advertising for a specific tobacco product and intentions to use that product again in the future, controlling for myriad covariates.

RESULTS

Advertising appeal was positively associated with future intentions to use again for electronic cigarettes (P = .006) and hookah (P = .001), but not cigars (P = .486), cigarillos (P = .126), or smokeless tobacco (P = .109).

CONCLUSION

Results suggest that advertising appeal may increase use of certain tobacco products among youth experiencing homelessness. However, differences in themes emphasized by advertising for specific tobacco products could differentially influence use in this population.

An exponential effect persistence model for intensive longitudinal data

We develop an effect persistence model for intensive longitudinal data under a general assumption of an exponential loss of association between exposure and outcome over time. The working model proposed may be useful for understanding the complexity of phenomena for which subjects can be repeatedly exposed to an intervention or a naturally occurring event, while, the effect of any one exposure is expected to diminish over time. Under the main assumption, we specify a semilinear model with extensions to generalized linear models. These methods are motivated by, and applied to, data from a study of adolescent exposure to prosmoking advertisement in which the impact of prosmoking media exposure on young adults' susceptibility to smoking is assessed along with the decay of the effect over time. We investigate the performance of the proposed method when the model assumptions are correctly specified or not. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Residential environments and smoking behaviour patterns among young adults: A prospective study using data from the Interdisciplinary Study of Inequalities in Smoking cohort

Young adults have the highest prevalence of smoking among all age groups. Studies have shown associations between presence/density of tobacco retail and presence of smoker accommodation and smoking prevalence. However, little is known about their potential to influence different smoking patterns including initiation, maintenance, or cessation. This is important because smoking behaviour patterns in young adults may be subject to ongoing changes. Moreover, smoking pattern determinants may be different to those of smoking prevalence, and feature-pattern associations may be scale-dependent, requiring the consideration of different analytical spatial units. We examined associations between prospectively-measured smoking behaviour patterns and presence/density of tobacco retail, and presence of smoker accommodation facilities across 2 nested spatial units in Montreal, Canada. Data were from 18 to 25 year-old Montreal residents who had participated in the Interdisciplinary Study of Inequalities in Smoking cohort both at baseline in 2011-2012 and follow-up in 2014 and resided in the same area at follow-up. 2-year smoking behaviour patterns were assessed for 2 cohorts based on participants' smoking status at baseline. Associations were examined using multilevel logistic models. Young adults who were smokers at baseline residing in areas with higher local-level presence of tobacco retail were less likely to quit smoking (i.e.: to be non-smokers for fewer than 2 years). Higher presence of smoker accommodation was not associated with smoking patterns at any scale. Findings provide evidence of scale-specific associations between residential environment features and smoking behaviour patterns in young adults, which may point to specific exposure-outcome processes underlying these associations.

The magnitude and impact of tobacco marketing exposure in adolescents' day-to-day lives: An ecological momentary assessment (EMA) study

PURPOSE

Research indicates that tobacco marketing contributes to higher pro-tobacco attitudes and behaviors among adolescents, but no studies have been able to assess the impact of real-world tobacco marketing exposures in real-time. The purpose of this study was to examine the magnitude and impact of tobacco marketing exposure on adolescents using ecological momentary assessment (EMA). Our primary hypotheses were that (1) youth would most frequently report tobacco marketing at the retail points-of-sale and (2) greater exposures to tobacco marketing would be associated with more favorable tobacco-related attitudes, use, and expectancies.

METHODS

Participants were adolescent males from rural and urban Ohio (N = 176, ages 11-16). For ten days, these adolescents were prompted at two-three random times/day to complete a brief smartphone-based survey about their exposures and responses to tobacco-related advertising.

RESULTS

Adolescents reported exposures to tobacco marketing an average of 1.9 times over the 10-day EMA period, with over 10% seeing a tobacco advertisement 5 or more times. Reports of marketing exposures occurred most frequently at the point-of-sale; exposures were higher among tobacco users and rural adolescents. Consistent with hypotheses, marketing exposure was related to more positive attitudes to the tobacco advertisements, more tobacco use, and higher expectancies to use in the future.

CONCLUSIONS

Overall, these findings signal the magnitude of tobacco marketing exposures and their pernicious impact on youth. Findings underscore the importance of federal, state, and local-level tobacco regulatory policies to protect youth from the marketing that puts them at risk for a lifetime of nicotine addiction and tobacco-related diseases.

Pro-tobacco advertisement exposure among African American smokers: An ecological momentary assessment study

INTRODUCTION

Many African Americans live in communities with a disproportionately high density of tobacco advertisements compared to Whites. Some research indicates that point-of-sale advertising is associated with impulse purchases of cigarettes and smoking. Ecological Momentary Assessment (EMA) can be used to examine associations between tobacco advertisement exposure and smoking variables in the natural environment.

METHODS

Non-treatment seeking African American smokers were given a mobile device for 2weeks (N=56). They were prompted four times per day and responded to questions about recent exposure to tobacco advertisements. Participants were also asked to indicate the number of cigarettes smoked, and if they made any purchase, or an impulse purchase, since the last assessment. Linear mixed models (LMMs) analyzed between- and within-subject associations between exposure and outcomes.

RESULTS

Participants reported seeing at least one advertisement on 33% of assessments. Of those assessments, they reported seeing menthol advertisements on 87% of assessments. Between-subject analyses revealed that participants who on average saw more advertisements were generally more likely to report purchasing cigarettes and to purchase cigarettes on impulse. Within-subject analyses revealed that when an individual participant reported seeing more advertisements than usual they were more likely to have reported purchasing cigarettes, making an impulse purchase and smoking more cigarettes during the same period, but not the subsequent time period.

CONCLUSIONS

Many African American smokers are frequently exposed to pro-tobacco marketing. Advertisement exposure is cross-sectionally associated with impulse purchases and smoking. Future research should assess prospective associations in more detail.

Media/Marketing Influences on Adolescent and Young Adult Substance Abuse

PURPOSE OF REVIEW

We describe the state of research on substance use portrayals in marketing and media, considering exposure to tobacco, alcohol, e-cigarette, and marijuana content. Putative mechanisms are offered, and recommendations made for effective prevention strategies for mitigating the influence of these portrayals.

RECENT FINDINGS

There is consistent evidence that adolescents and young adults are highly exposed to substance use portrayals and that these portrayals are associated with subsequent substance use. Exposure via new media (social networking sites, brand websites) has risen rapidly. Social norms and cognitions appear to at least partially account for the effects of portrayals on youth substance use.

SUMMARY

Digital media has surpassed traditional marketing, which is concerning because youth have on-demand access to content and are active consumers of digital media. Developmentally appropriate media literacy interventions that include a parenting component and target multiple substances and media domains are recommended.

Media/Marketing Influences on Adolescent and Young Adult Substance Abuse

PURPOSE OF REVIEW

We describe the state of research on substance use portrayals in marketing and media, considering exposure to tobacco, alcohol, e-cigarette, and marijuana content. Putative mechanisms are offered, and recommendations made for effective prevention strategies for mitigating the influence of these portrayals.

RECENT FINDINGS

There is consistent evidence that adolescents and young adults are highly exposed to substance use portrayals and that these portrayals are associated with subsequent substance use. Exposure via new media (social networking sites, brand websites) has risen rapidly. Social norms and cognitions appear to at least partially account for the effects of portrayals on youth substance use.

SUMMARY

Digital media has surpassed traditional marketing, which is concerning because youth have on-demand access to content and are active consumers of digital media. Developmentally appropriate media literacy interventions that include a parenting component and target multiple substances and media domains are recommended.

Acceptability and compliance with a remote monitoring system to track smoking and abstinence among young smokers

BACKGROUND

Similar to adult smokers, quit attempts among younger smokers almost inevitably result in relapse. Unlike adults, less is known about the process of relapse in this younger age group. A technology-based remote monitoring system may allow for detailed and accurate characterization of smoking and abstinence and would help to improve cessation strategies.

OBJECTIVES

This study describes a mobile system that captures smoking using breath carbon monoxide (CO) and real-time self-reports of smoking behavior. Compliance, feasibility, acceptability, and accuracy of the system were measured during a quit attempt and subsequent monitoring period.

METHODS

The mobile application (My Mobile Monitor, M3) combined breath CO with ecological momentary assessment, delivered via smartphone. Participants (N = 16; 75% female) were daily smokers between the ages of 19 and 25, who used the app for 11 days during which they agreed to make a quit attempt. Acceptability, compliance, and abstinence were measured.

RESULTS

Participants averaged 22.3 ± 2.0 years old and smoked an average of 13.0 ± 6.1 cigarettes per day. Overall session compliance was 69% and during the quit attempt, 56% of participants abstained from smoking for at least 24 hours. Agreement between self-reported smoking compared to breath CO was generally high, when available for comparison, though underreporting of cigarettes was likely.

CONCLUSION

This study demonstrates feasibility of a remote monitoring app with younger smokers, though improvements to promote compliance are needed. Remote monitoring to detect smoking and abstinence represents a step forward in the improvement of cessation strategies, but user experience and personalization are vital.

Effects of antismoking media on college students' smoking-related beliefs and intentions

Ecological momentary assessment was used to examine immediate changes in 87 college students' smoking-related attitudes, beliefs, and intentions as a joint function of their exposure to antismoking media and smoking status. Students (37 never smokers, 41 experimental smokers, and 9 current intermittent smokers) carried handheld data-collection devices for 3 weeks to record naturally occurring exposures to antismoking media and respond to investigator-initiated control prompts. At each reported exposure to antismoking media and each control prompt, participants reported their smoking-related attitudes, perceptions of the prevalence of smoking among their peers, resistance self-efficacy, and intentions to smoke. Mixed-effects regression was used to compare responses between encounters with antismoking media and control prompts. Experimental smokers reported weaker intentions to smoke and greater resistance self-efficacy at moments of exposure to antismoking media than at control prompts. Regardless of smoking experience, participants reported higher perceived prevalence of smoking at times of exposure to antismoking media than at control prompts. These findings generally support the value of antismoking media messages for shifting the beliefs and intentions of experimental smokers, who are at high risk for becoming committed regular smokers. (PsycINFO Database Record

Young adult non-smokers' exposure to real-world tobacco marketing: results of an ecological momentary assessment pilot study

Background

The aims of this pilot study were to assess and characterize non-current smoking young adults’ exposure to tobacco marketing through an ecological momentary assessment protocol.

Methods

Ecological momentary assessment (EMA) consists of repeated measurement of momentary phenomena and is well-suited to capture sporadic experiences in the real-world, such as exposure to tobacco marketing. EMA has the potential to capture detailed information about real-world marketing exposures in ways that reduce recall bias and increase ecological validity. In this study, young adults (n = 31; ages 18–25) responded to random prompts regarding their momentary exposure to tobacco marketing via text messages on their smartphones for 14 days (n = 1798 observations). Unadjusted and adjusted analyses were conducted using multilevel logistic regression to assess the odds of exposure accounting for correlation of multiple repeated measures within individuals while controlling for variability between individuals.

Results

Respondents reported, on average, two momentary exposures to tobacco advertising in the 14-day study period. In adjusted analyses, African–American (aOR 3.36; 95% CI 1.07, 10.54) and Hispanic respondents (aOR 5.08; 95% CI 1.28, 20.13) were more likely to report exposure to tobacco advertising. Respondents were also more likely to report exposure when also exposed to others using tobacco products and when they were at stores compared with at home (aOR 14.82; 95% CI 3.61, 60.88).

Conclusion

Non-smoking young adults report exposure to tobacco marketing particularly at the point-of-sale, with the highest likelihood of exposure among African-American and Hispanic young people. EMA protocols can be effective in assessing the potential impact of point-of-sale tobacco marketing on young adults.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2758-7) contains supplementary material, which is available to authorized users.

Tracking Young Adults' Attitudes Toward Tobacco Marketing Using Ecological Momentary Assessment (EMA)

BACKGROUND

Decades of research demonstrate the pernicious effects of targeted cigarette marketing on young people. Now, with tobacco marketing shifting toward greater incorporation of alternative products, it is critical to identify current attitudes toward the new landscape of tobacco advertisements.

OBJECTIVES

The purpose of this study was to understand the present landscape of tobacco marketing to which young adults are exposed, and to assess how they respond to it.

METHOD

During 2015-2016, we used ecological momentary assessment (EMA), in which 44 young adults (aged 18-28) carried smartphones equipped with a survey app. Seventy-seven percent were ever-users of tobacco and 29.5% were intermittent users of tobacco (someday users of cigarettes and/or those who used another tobacco product >5 times within the past year). For ten days, participants were prompted at three random times/day to complete a brief survey about their exposures and responses to tobacco-related advertising. Analyses used t-test and multilevel modeling.

RESULTS

Intermittent users reported greater exposure than non-intermittent users to tobacco advertising. Further, both intermittent and ever-users reported more positive attitudes toward the tobacco advertising. Of the tobacco advertisements reported, 22% were for products unregulated by the FDA at the time of data collection. Conclusions/Importance: These findings indicate that young adults, and especially young adults who use tobacco, are exposed to a fair amount of tobacco advertising on a weekly basis. As the tobacco users in our sample were largely experimental and occasional users, these marketing exposures could put young adults at risk for progression toward regular use.

How social media influence college students' smoking attitudes and intentions

Building on the influence of presumed influence (IPI) model, this study examines how smoking- related messages on social media influence college students' smoking. We surveyed 366 college students from three U.S. Midwestern universities in 2012 and examined the effects of expression and reception of smoking-related messages on smoking using path analysis. We found that the expression and reception of prosmoking messages not only directly affected smoking but also had indirect effects on smoking through (1) perceived peer expression of prosmoking messages and (2) perceived peer smoking norms. For antismoking messages, only reception had a significant indirect influence on smoking through (1) perceived peer reception of antismoking messages and (2) perceived peer smoking norms. In conclusion, social media function as an effective communication channel for generating, sharing, receiving, and commenting on smoking-related content and are thus influential on college students' smoking.

Qualitative exploration of young adult RYO smokers' practices

BACKGROUND

Although roll-your-own (RYO) tobacco often elicits negative connotations of a lower class product, uptake and use by young adult smokers has grown because RYO is more cost-effective than tailor-made (TM) cigarettes. We explored the practices and beliefs young adults develop to distance themselves from unattractive stereotypes of RYO smokers.

METHODS

We conducted 20 in-depth interviews with New Zealand young adult RYO users aged between 18 and 30 years, and used thematic analysis to interpret the transcripts.

RESULTS

We identified three themes: establishing the superiority of RYO tobacco; creating and enacting usage rituals, and ritual disruption. Participants regarded RYO tobacco as more natural and better-tasting; they used it to control their tobacco use and facilitate interactions with others. Many described rolling rituals where they used specific artefacts and microbehaviours to construct cigarettes they saw as personal and artisanal. Several, though not all, disliked unattractively coloured papers as these disrupted the value their rituals created.

CONCLUSIONS

Young adults imbue RYO tobacco with positive attributes, many of which centre on rolling rituals or draw on widely held misperceptions of RYO tobacco as less harmful. Excise tax increases could counter perceptions of RYO as more cost-effective while mandating that dissuasively coloured paper could disrupt reduced-harm connotations. However, evidence that erroneous harm beliefs are widespread and entrenched may justify restricting or eliminating the key artefact-the product itself.

Tobacco cues in India: An ecological momentary assessment

BACKGROUND

Tobacco use in India is a major health concern; however, little is known about the influence of tobacco-related social and environmental cues on tobacco use. This study uses ecological momentary assessment (EMA) to examine real-time tobacco use and exposure to social and environmental cues.

METHODS

In Hyderabad and Kolkata, participants were recruited, and an EMA application was installed on their mobile phones. Momentary prompts (MP) were randomly used to collect real-time information and end-of-day (EOD) prompts gathered retrospective information on daily basis. Besides personal tobacco use, the surveys asked about exposure to social (e.g., presence of others using tobacco) and environmental cues (e.g., visual and olfactory stimuli). Using the data aggregation approach, bivariate and multivariate analyses were performed to examine the association of tobacco use and cue exposure. Moderating roles of participants' socio-demographic characteristics were also tested to gain an in-depth understanding of the relationship.

RESULTS

Among the 205 participants, around a third (MP, 33.7 %; EOD, 37.6 %) used tobacco at least once during the study period. Tobacco-related social and environmental cues related were commonly reported. In the bivariate models, tobacco use was associated with gender, age, and all the examined social and environmental cues except for seeing restrictions on tobacco use. In the multivariate models, tobacco use was associated with age, gender, seeing others using tobacco, and seeing restrictions on tobacco use. Seeing others in one's immediate group using tobacco was the strongest predictor of tobacco use in both MP and EOD assessments. Gender and age did not moderate the relationship between cue exposure and tobacco use, although males reported higher tobacco use and cue exposure in general.

CONCLUSIONS

This research provides data on the ubiquity of social and environmental tobacco cues in India. The EMA approach was feasible and informative. Future cessation interventions and advocacy efforts should address the high prevalence of tobacco use and exposure to pro-tobacco use cues especially among Indian males. Health education campaigns for promoting tobacco use restrictions in private places as well as changing the norms of tobacco use in social settings are recommended.

Using Ecological Momentary Assessment to Study Tobacco Behavior in Urban India: There's an App for That

Background

Ecological momentary assessment (EMA) uses real-time data collection to assess participants’ behaviors and environments. This paper explores the strengths and limitations of using EMA to examine social and environmental exposure to tobacco in urban India among older adolescents and adults.

Objective

Objectives of this study were (1) to describe the methods used in an EMA study of tobacco use in urban India using a mobile phone app for data collection, (2) to determine the feasibility of using EMA in the chosen setting by drawing on participant completion and compliance rates with the study protocol, and (3) to provide recommendations on implementing mobile phone EMA research in India and other low- and middle-income countries.

Methods

Via mobile phones and the Internet, this study used two EMA surveys: (1) a momentary survey, sent multiple times per day at random to participants, which asked about their real-time tobacco use (smoked and smokeless) and exposure to pro- and antitobacco messaging in their location, and 2) an end-of-day survey sent at the end of each study day. Trained participants, from Hyderabad and Kolkata, India, reported on their social and environmental exposure to tobacco over 10 consecutive days. This feasibility study examined participant compliance, exploring factors related to the successful completion of surveys and the validity of EMA data.

Results

The sample included 205 participants, the majority of whom were male (135/205, 65.9%). Almost half smoked less than daily (56/205, 27.3%) or daily (43/205, 21.0%), and 4.4% (9/205) used smokeless tobacco products. Participants completed and returned 46.87% and 73.02% of momentary and end-of-day surveys, respectively. Significant predictors of momentary survey completion included employment and completion of end-of-day surveys. End-of-day survey completion was only significantly predicted by momentary survey completion.

Conclusions

This first study of EMA in India offers promising results, although more research is needed on how to increase compliance. End-of-day survey completion, which has a lower research burden, may be the more appropriate approach to understanding behaviors such as tobacco use within vulnerable populations in challenging locations. Compliance may also be improved by increasing the number of study visits, compliance checks, or opportunities for retraining participants before and during data collection.

Review of hookah tobacco smoking among college students: policy implications and research recommendations

BACKGROUND

About 30% of college students have smoked hookah tobacco. Although most students perceive this product to be innocuous and non-addictive, hookah tobacco increases the risk for disease and nicotine dependence. Currently, the US Food and Drug Administration (FDA) does not regulate the manufacture, distribution, or sale of hookah tobacco.

OBJECTIVE

Empirical literature pertaining to hookah tobacco smoking is reviewed with a focus on the implications for regulatory policy.

METHODS

PubMed, PsycINFO, and Scopus databases were searched to locate articles published in English. The literature search combined several key words including "hookahs", "college", "advertising", "health effects", and "health policy".

RESULTS

Smoking hookah tobacco may play a role in the initiation of smoking among tobacco-naïve college students and may portend persistent smoking among those who have smoked cigarettes. College students are typically nondaily, social smokers. They do not perceive that their heightened risk for tobacco diseases and nicotine dependence relates to their smoking behavior. However, few public health messages target college-age adults to counter media messages that endorse hookah tobacco smoking.

CONCLUSION

Given that the FDA is not authorized to ban specific tobacco products, policy actions should focus on the development of effective risk communication strategies that target college-age adults and on limiting the accessibility of hookah tobacco products to these adults. Accordingly, a research agenda that would inform these policy actions is proposed.

Quantifying the persistence of pro-smoking media effects on college students' smoking risk

PURPOSE

To quantify the persistence of pro-smoking media exposure effects on college students' intentions to smoke and smoking refusal self-efficacy.

METHOD

A total of 134 college students (ages 18-24 years) were enrolled in an ecological momentary assessment study in which they carried handheld data collection devices for 3 weeks and reported their exposures to pro-smoking media as they occurred in the real world. Smoking intentions and smoking refusal self-efficacy were assessed after each exposure to pro-smoking media and at random prompts during each day of the 3-week assessment period. A generalized additive model was used to determine how long the effect of an exposure to pro-smoking media persisted.

RESULTS

The effect of pro-smoking media exposures persisted for 7 days. After exposure, smoking intentions immediately increased (.56; 95% confidence interval [CI]: [.26, .87]) and then steadily decreased (-.12; 95% CI: [-.19, -.05]) each day for 7 days, while smoking refusal self-efficacy immediately decreased (-.42; 95% CI: [-.75, -.10]) and then steadily increased (.09; 95% CI: [.02, .16]) each day for 7 days. Daily changes occurring after 7 days were not statistically significant, suggesting that smoking intentions and refusal self-efficacy had stabilized and were no longer affected by pro-smoking media exposure.

CONCLUSIONS

Exposures to pro-smoking media may have strong implications for emerging young adults smoking risk as the impact of an individual exposure appears to persist for at least a week.

Conceptualizing analyses of ecological momentary assessment data

Ecological momentary assessment (EMA) methods, which involve collection of real-time data in subjects' real-world environments, are particularly well suited to studying tobacco use. Analyzing EMA datasets can be challenging, as the datasets include a large and varied number of observations per subject and are relatively unstructured. This paper suggests that time is typically a key organizing principle in EMA data and that conceptualizing the data as a timeline of events, behaviors, and experiences can help define analytic approaches. EMA datasets lend themselves to answering a diverse array of research questions, and the research question must drive how data are arranged for analysis, and the kinds of statistical models that are applied. This is illustrated this with brief examples of diverse analyses applied to answer different questions from an EMA study of tobacco use and relapse.

Exposure to pro-smoking media in college students: does type of media channel differentially contribute to smoking risk?

BACKGROUND

There are almost no data on whether the different channels through which pro-smoking media appear (i.e., point-of-sale advertising, movie smoking) differently influence smoking.

PURPOSE

This study used ecological momentary assessment to examine whether differences in smoking risk were observed for exposures to different pro-smoking media channels.

METHODS

College students (n = 134) carried smartphones for 21 days, recording their exposures to pro-smoking media and the media channels for that exposure and responding to three randomly issued control prompts per day. Participants answered questions about their future smoking risk after each pro-smoking media exposure and random prompt.

RESULTS

Participants had elevated future smoking risk following exposure to pro-smoking media at point of sale (p < 0.001); smoking risk at times of exposure to smoking in movies did not differ from risk measured during control prompts (p = 0.78).

CONCLUSIONS

There is merit to examining the relative contribution of different pro-smoking media channels to smoking behavior.

Compliance with an EMA monitoring protocol and its relationship with participant and smoking characteristics

INTRODUCTION

Arguably, the greatest advantage of ecological momentary assessment (EMA) studies is that data are collected repeatedly in real-time and real-world situations, which reduces recall and situational biases and thus improves the accuracy and validity of the data collected. However, the validity of EMA data is contingent upon compliance rates. If participant characteristics are related to missing data, analyses should control for these factors, or they should be targeted in EMA training sessions. This study evaluates the impact of demographic and smoking-related participant characteristics on compliance to an EMA smoking study protocol.

METHODS

Prequit-day data were taken from the control arm of an ongoing randomized controlled trial of a smoking-cessation program. After training, 119 participants were asked to carry a mobile device with them at all times for ~6 days and to log every cigarette they smoked in addition to completing randomly scheduled assessments. Different types of compliance were assessed: the percentage of completed random prompts (signal-contingent compliance), the percentage of logged cigarettes per day compared to a timeline follow-back measure, and the correlation between logged cigarettes and a carbon monoxide assessment 2 hr later (both event-contingent compliance).

RESULTS

Overall compliance rates were 78.48% for event-contingent and 72.17% for signal-contingent compliance. None of the demographic or smoking-related participant characteristics predicted signal-contingent compliance; however, female participants showed higher event-contingent compliance than male participants, and Caucasian participants showed higher event-contingent compliance than non-Caucasian participants.

CONCLUSIONS

Compliance did not depend on smoking-related characteristics. EMA is a valid method for assessing smoking behavior in real-time and real-world settings.

Middle and high school students' exposure to alcohol- and smoking-related media: a pilot study using ecological momentary assessment

The goals of this study were to assess the feasibility of using Ecological Momentary Assessment (EMA) to measure adolescents' exposure to alcohol and smoking-related media. A sample of 20 middle and high school students completed a 2-week EMA protocol in which they monitored exposures to alcohol and smoking-related media. Results showed that adolescents were highly compliant with the study protocol. A total of 255 exposures to alcohol (67%) and smoking (33%) were captured, representing an average of 8.50 (SD = 5.82) alcohol-related media exposures and 4.25 (SD = 3.67) smoking-related media exposures per participant, during the study period. Exposures tended to occur in the afternoon (52% alcohol; 54% smoking), at point of sale (44% alcohol; 65% smoking), and on days leading up to the weekend (57% alcohol; 57% smoking). Exposures were also likely in the presence of family (69% alcohol; 56% smoking). Overall, results of this small pilot provide preliminary evidence that EMA is a useful tool for tracking and characterizing middle and high school students' real-world exposures to alcohol- and smoking-related media. Future studies may suggest mechanisms by which media exposures lead to youth uptake of drinking and smoking behaviors.

Friends moderate the effects of pro-smoking media on college students' intentions to smoke

Exposure to prosmoking media (e.g., smoking in movies, advertising in magazines) contributes to smoking in young people. However, the extent to which the impact of exposure depends on the social context in which those exposures occur has not been investigated. This study used ecological momentary assessment to examine the moderating role of social context in the relationship between college students' exposure to prosmoking media and their smoking refusal self-efficacy and intention to smoke. College students (n = 134) carried handheld computers for 21 days, recording their exposure to all forms of prosmoking media during the assessment period. They also responded to three investigator-initiated control prompts (programmed to occur randomly) each day of the assessment. After each exposure to prosmoking media and after each control prompt, participants answered questions about smoking refusal self-efficacy and their intentions to smoke; they also indicated whether they were with friends, with family, with a romantic partner, or alone (i.e., their social context). When participants were with friends, prosmoking media exposures were associated with stronger smoking intentions and lower smoking refusal self-efficacy; these associations were not present when participants were alone. Being with family members or with a romantic partner did not moderate the impact of prosmoking media exposure on either dependent variable. These results suggest a new role for peers in the development of youth smoking.