Comparison of Message and Effects Perceptions for The Real Cost E-Cigarette Prevention Ads

Understanding Potential Mechanisms of Vaping Prevention Messages: A Mediation Analysis of the Real Cost Campaign Advertisements

The U.S. Food and Drug Administration (FDA) developed a public education campaign, The Real Cost, that reduced youth susceptibility to tobacco product use. We sought to identify the mechanisms that may underlie the impact of The Real Cost ads on susceptibility to vaping to inform youth tobacco prevention campaigns. Our online randomized controlled trial (clinicaltrials.gov, identifier NCT04836455) examined a large sample of U.S. adolescents (n = 1,348) who had multiple exposures to Real Cost ads or control videos over a 3-week period in 2021. To examine potential mediating pathways between The Real Cost ads and susceptibility to vaping, we examined theory-based psychosocial and message-related variables. The largest impact of The Real Cost ads on susceptibility was via more negative attitudes toward vaping (βa*βb = -0.16; 95% confidence interval [CI] = [-0.25, -0.06]). Other mediation paths were via improved health harm risk beliefs (βa*βb = -0.08; 95% CI = [-0.13, -0.04]), addiction risk beliefs (βa*βb = -0.04; 95% CI = [-0.06, -0.01]), injunctive norms against vaping (βa*βb = -0.05; 95% CI = [-0.09, -0.02]), negative affect (βa*βb = -0.05; 95% CI = [-0.08, -0.02]), and cognitive elaboration (βa*βb = -0.03; 95% CI = [-0.05, -0.003]). Our findings suggest that ads that target negative attitudes may decrease susceptibility to vaping among youth. Our findings also introduce normative pressure as a novel factor that may be important for vaping prevention messages.

Quitting on TikTok: Effects of Message Themes, Frames, and Sources on Engagement with Vaping Cessation Videos

This study examined how message themes, frames, and sources in vaping cessation videos on TikTok influenced positive (i.e. likes, shares, positive comments regarding quitting vaping) and negative video engagement (i.e. negative comments regarding quitting vaping). TikTok videos (N = 412) with the hashtags #quitvaping and #quittingvaping were analyzed. Aspect-based sentiment analysis was conducted to evaluate the sentiment of quitting vaping in comments. Negative binomial regression models predicted video engagement from six message themes, ratios of gain and loss frames, and message sources. Themes related to nicotine addiction and physical health effectively drove positive engagement, such as likes and shares. The theme of harmful chemicals elicited mixed responses, generating both positive and negative comments regarding quitting vaping. Videos with a higher ratio of gain frames led to more positive engagement, including likes, shares, and positive comments regarding quitting vaping. Sources with informal expertise (e.g. those who have successfully quit vaping) and current e-cigarette users were more effective in engaging the TikTok audience than non-expert and non-user sources. These findings provide insights into messaging strategies that can effectively engage TikTok audiences and encourage vaping cessation.

Examining the Longitudinal Relationship Between Perceived and Actual Message Effectiveness: A Randomized Trial

We sought to examine the relationship between perceived message effectiveness (PME) and actual message effectiveness (AME) in a 3-week randomized trial of vaping prevention advertisements. Participants were US adolescents (n = 1,514) recruited in 2021. We randomly assigned them to view The Real Cost vaping prevention ads or control videos online. Participants viewed three videos at Visit 1, again at Visits 2 and 3, and completed a survey at each visit that assessed AME (susceptibility to vaping) and two types of PME - effects perceptions (potential for behavioral impact) and message perceptions (potential for message processing). At Visit 4, AME was measured. Compared to control, The Real Cost ads led to improved AME (lower susceptibility to vaping at Visit 4, p < .001). This was anticipated by The Real Cost ads eliciting higher PME ratings (higher effects and message perceptions at Visit 1, both p < .001). Furthermore, PME (both effects and message perceptions) at Visit 1 predicted susceptibility to vaping at Visits 1, 2, 3, and 4 (all p < .001). Finally, effects perceptions fully mediated the impact of The Real Cost ads on susceptibility to vaping (β = -.30; p < .001), while message perceptions only partially mediated the effect (β = -.04; p = .001). Our findings indicate a relationship between PME and AME, especially effects perceptions, and suggest that PME may be useful in message pre-testing to select messages with greater behavior change potential.

Does source matter? Examining the effects of health experts, friends, and social media influencers on young adult perceptions of Instagram e-cigarette education messages

PURPOSE

Young adults' e-cigarette use is a leading public health concern. Using messages from credible sources can help improve message acceptance, yet little research has examined the role of source credibility on young adults' responses to e-cigarette education messages.

METHODS

We examined the impact of source on young adults' perceptions of e-cigarette education messages and e-cigarettes. In July 2022, we conducted an experimental study using an online sample of young adults (N=459, Mage=24.6) who were randomized to one of three source conditions: expert, friend, or influencer, and viewed e-cigarette education messages. We used one-way ANOVA to estimate the association between the conditions and outcomes (perceived source credibility, message trust, curiosity, use interests, perceived message effectiveness, beliefs, harm perceptions, and intentions to refrain).

RESULTS

The expert condition was associated with significantly higher perceived source credibility (vs. friend, influencer; p<0.001), message trust (vs. friend, influencer; p<0.001), and curiosity (vs. influencer; p's<0.05).

CONCLUSIONS

Public health campaigns may leverage health experts to deliver e-cigarette education messages targeting young adults to improve effectiveness of the messages.

Why Do People Believe in Vaccine Misinformation? The Roles of Perceived Familiarity and Evidence Type

The proliferation of health misinformation poses a significant threat to public health, making it increasingly important to understand why misinformation is accepted. The illusory truth effect, which refers to the increased believability of a message due to repeated exposure, has been widely studied. However, there is limited research on this effect in the context of COVID-19 vaccine misinformation. This paper aims to examine the role of perceived familiarity with COVID-19 vaccine misinformation on various message perceptions, including perceived accuracy, agreement, perceived message effectiveness, and determinants of vaccination, including vaccine attitude and vaccination intention. Furthermore, it explores the impact of misinformation evidence (statistical vs. narrative) on the magnitude of the effects of perceived familiarity. To investigate these factors, a between-subjects experimental study was conducted, employing a 2 (Familiarity: strong vs. weak) × 3 (Evidence type: statistical, narrative, and both evidence) + 1 (Control: a message about drinking water) design. The results revealed that perceived familiarity with COVID-19 vaccine misinformation significantly predicted perceived accuracy, which was found to be negatively correlated with vaccine attitudes and vaccination intentions. Moreover, statistical evidence presented in misinformation was perceived as more persuasive in perceived message effectiveness, compared to narrative and mixed evidence. Interestingly, the effects of perceived familiarity were not contingent on the type of evidence used in COVID-19 vaccine misinformation. These findings emphasize the importance of avoiding the repetition of misinformation, reducing the processing fluency associated with misinformation correction, and educating individuals on how to critically evaluate statistical evidence when encountering (mis)information.

Valence of YouTube Comments and College Student Reactions Towards Electronic Nicotine Product Counter-Marketing Messages

Advertisements promoting and discouraging electronic nicotine products (ENPs) are widespread on social media. User interaction is a hallmark feature of social media sites. This study examined how user-comment valence (i.e. positive versus negative comments) influences attitudes toward counter-marketing ads, and determinants of ENP abstinence according to the theory of planned behavior (TPB). College students were randomly assigned to one of three conditions, a positive comment condition (n = 121), in which they were shown a YouTube comment section with eight positive comments and two negative comments; a negative comment condition (n = 126), in which they were shown a YouTube comment section with eight negative and two positive comments; and a control condition (n = 128). Then, all groups were shown a YouTube video advocating for ENP abstinence and completed measures about their attitudes toward the ad (Aad), attitudes toward ENP abstinence, injunctive and descriptive norms about ENP abstinence, perceived behavioral control (PBC) toward ENP abstinence, and intention to abstain from ENPs. Results indicated that exposure to negative comments yielded significantly less favorable Aad when compared to the positive condition, but no difference in Aad was observed between the negative and control conditions, or between the positive and control conditions. Further, there were no differences for any determinants of ENP abstinence. Additionally, Aad mediated the effects of negative comments on attitudes toward ENP abstinence, injunctive norms and descriptive norms about ENP abstinence, and behavioral intention. Findings indicate that negative user comments depress attitudes toward counter-persuasion ads targeting ENP use.

Evaluating The Real Cost Digital and Social Media Campaign: Longitudinal Effects of Campaign Exposure on E-cigarette Beliefs

INTRODUCTION

Over the past decade, youth e-cigarette use has risen exponentially. At the same time, digital media use increased markedly while the use of traditional broadcast TV declined. In response, the U.S. Food and Drug Administration's The Real Cost public education campaign shifted to communicating the harms of e-cigarette via primarily digital and social platforms. This study evaluated longitudinal associations between exposure to campaign advertisements and changes in campaign-specific beliefs among US youth.

METHODS

A nationally representative longitudinal cohort of youth (aged 11-16 years at baseline) was surveyed five times. Building on earlier work, we analyzed data from the last three waves (April-July 2020; January-April 2021; and August-October 2021; N = 2625). We assessed self-reported exposure to six ads and agreement with 11 beliefs that were each targeted by one or more ads. Eleven weighted panel regression models assessed whether ad exposure predicted changes in campaign-specific beliefs over time.

RESULTS

We observed significant associations between ad exposure and increases in at least one campaign-specific belief for five of the six ads. Across the 11 beliefs, we observed associations between increased exposure and increases in 6 beliefs related to e-cigarettes and toxic metals, lung damage, dangerous ingredients, anxiety, cigarette use, and disappointing important people.

CONCLUSIONS

We found evidence that self-reported exposure to this digital and social media campaign was successful at influencing youth, providing support for the effectiveness of the campaign's adaption to address youth's changes in tobacco and media use habits.

IMPLICATIONS

The Food and Drug Administration's The Real Cost public education campaign educates youth about the dangers of e-cigarette use. This study evaluates longitudinal associations between exposure to The Real Cost's advertisements and changes in campaign-specific beliefs among youth. Considering evolving trends in youth media consumption, the campaign adapted its media approach to increase delivery across digital and social media platforms. Our findings indicate that the campaign reached its intended audience and increased youth beliefs around the harm of e-cigarettes and the consequences of e-cigarette use, offering evidence for the effectiveness of digital and social media youth prevention efforts within a fragmented digital environment.

Development of the UNC Perceived Message Effectiveness Scale for Youth

PURPOSE

Tobacco prevention media campaigns are an important tool to address youth tobacco use. We developed a theory-based perceived message effectiveness (PME) Scale to use when vetting messages for campaigns.

METHODS

Participants were a national sample of N=623 US adolescents (ages 13-17 years) recruited from a national probability-based panel. In an online experiment, we randomised adolescents to view tobacco prevention ads. All participants viewed an ad on smoking or vaping from the US Food and Drug Administration's The Real Cost campaign and a control video, in a random order. After ad exposure, we assessed PME using nine candidate items and constructs for convergent and criterion validity analyses. We used confirmatory factor analysis and examined information curves to select the scale items.

RESULTS

A brief PME scale with three items (α=0.95) worked equally well for demographically diverse adolescents with different patterns of tobacco use. The Real Cost ads generated higher PME scores than the control videos for both vaping and smoking (convergent validity; p<0.05). Higher PME scores were associated with greater attention, fear, cognitive elaboration and anticipated social interactions (convergent validity; r=0.31-0.66), as well as more negative attitudes toward and lower susceptibility to vaping and smoking (criterion validity; r=-0.14 to -0.37). A single-item PME measure performed similarly to the three-item version.

CONCLUSIONS

The University of North Carolina PME Scale for Youth is a reliable and valid measure of the potential effectiveness of vaping and smoking prevention ads. Employing PME scales during message development and selection may help youth tobacco prevention campaigns deploy more effective ads.

Perceived effectiveness of objective elements of vaping prevention messages among adolescents

INTRODUCTION

In recent years, vaping prevention campaigns have proliferated in response to a surge of e-cigarette use among adolescents in the USA. To date, the research literature has provided minimal guidance as to what vaping prevention message elements have the greatest potential for discouraging vaping, are ineffective or have unintended negative effects. The purpose of the current study was to identify and test a large set of vaping prevention ads used by federal, state, local and non-governmental agencies, examining how objectively coded message elements of vaping prevention messages might affect youth.

METHODS

A convenience sample of adolescents (N=1501) completed an online survey with each participant rating seven randomly selected vaping prevention ads from a pool of 220 ads on perceived message effectiveness (PME) and vaping appeal. Ads were coded on 37 objective elements in three message categories: themes, imagery and other features. Analyses examined how objective elements predicted PME.

RESULTS

Addiction, chemicals, negative health symptoms and effects, and cigarette comparison themes were associated with higher PME, as were graphic images and warning symbols. Industry targeting, environmental impact, flavour themes, images of food and people's faces were associated with lower PME, as were hashtags, statistics and first-person language or the word 'teen'. Most elements were not associated with appeal, but ads with a flavour theme were associated with increased vaping appeal.

CONCLUSION

Promising vaping prevention messages focus on the adverse consequences of vaping, use negative imagery and avoid speaking for teens using their vernacular or perspective.

Do Vaping Prevention Messages Impact Adolescents and Young Adults? A Meta-Analysis of Experimental Studies

Vaping prevention messages are widely used to communicate the health harms and addiction risks of vaping and discourage vaping among adolescents and young adults. We conducted a meta-analysis of experimental studies to examine the effects of these messages and to understand their theoretical mechanisms. Systematic, comprehensive searches generated 4,451 references, among which 12 studies (cumulative N = 6,622) met inclusion criteria for the meta-analysis. Across these studies, a total of 35 different vaping-related outcomes were measured, and 14 outcomes assessed in two or more independent samples were meta-analyzed. Results showed that compared to control, exposure to vaping prevention messages led to higher vaping risk perceptions, including harm perceptions (d = 0.30, p < .001), perceived likelihood of harm (d = 0.23, p < .001), perceived relative harm (d = 0.14, p = .036), addiction perceptions (d = 0.39, p < .001), perceived likelihood of addiction (d = 0.22, p < .001), and perceived relative addiction (d = 0.33, p = .015). Also, compared to control, exposure to vaping prevention messages led to more vaping knowledge (d = 0.37, p < .001), lower intentions to vape (d = -0.09, p = .022), and higher perceived message effectiveness (message perceptions; d = 0.57, p < .001; effects perceptions; d = 0.55, p < .001). Findings suggest vaping prevention messages have an impact, yet may operate through different theoretical mechanisms than cigarette pack warnings.

Can Extant Vaping Prevention Message Experiments Tell Us Something About What Works? A Response to O'Keefe

In his commentary, O'Keefe raises some interesting questions about the meaning of effect sizes in meta-analyses of experiments, focusing on our recent meta-analysis on vaping prevention messages. In this commentary, we respond to O'Keefe's comments and make several points. First, it is not uncommon to include experiments with different control conditions in a meta-analysis. Second, the set of studies in our meta-analysis were relatively homogenous, all being experiments testing messages to discourage vaping among adolescents and young adults. Third, the control conditions in each of the studies in the meta-analysis were appropriate for each given study, and our results show homogenous effects on most outcomes. Fourth, our meta-analysis finds meaningful effects that are timely and will be useful to researchers and practitioners alike. As this literature continues to grow, so too will knowledge about the effects of vaping prevention messages and moderators of those effects.

An Exploratory Study on Strategies Adopted by Parents Who Use E-Cigarettes to Negotiate Risk Perceptions of Their Children's Secondhand Exposure and Parental Role Modeling

Existing health messages mainly targeted youth susceptible to vaping or parents who do not have much knowledge about e-cigarettes. This study makes a unique contribution by conducting the first in-depth investigation of e-cigarette-using parents' risk perceptions and parental role modeling and how these two factors affect their vaping behaviors at home or implementation of any strategies to reduce their children's risk. Fifteen parents who used e-cigarettes participated in a semi-structured interview. Interview transcripts were coded and analyzed through a deductive approach of thematic analysis. This study demonstrates the need to develop and disseminate future health messages for e-cigarette-using parents who may have low-risk perceptions of secondhand exposure or who have adopted ineffective strategies to reduce their children's exposure. This study also identifies some possible targets for future intervention efforts through these parents including increasing their knowledge about the health risk of secondhand exposure to e-cigarettes, emphasizing the caregiver role, and effective communications with children about the consequences of vaping.

Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults

BACKGROUND

The US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings.

METHODS

Data were collected from a nationally representative sample of US young adult (18-29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME).

RESULTS

Participants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46).

CONCLUSIONS

Pictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.

The Impact of The Real Cost Vaping and Smoking Ads across Tobacco Products

INTRODUCTION

Little research has examined the spillover effects of tobacco communication campaigns, such as how anti-smoking ads affect vaping.

AIMS AND METHODS

Participants were a national sample of 623 U.S. adolescents (ages 13-17 years) from a probability-based panel. In a between-subjects experiment, we randomly assigned adolescents to view one of four videos online: (1) a smoking prevention video ad from the Food and Drug Administration's (FDA) The Real Cost campaign, (2) a neutral control video about smoking, (3) a vaping prevention video ad from The Real Cost campaign, or (4) a neutral control video about vaping. We present effect sizes as Cohen's d, standardized mean differences, with 95% confidence intervals (CIs).

RESULTS

Exposure to The Real Cost vaping prevention ads led to more negative attitudes toward vaping compared with control (d = 0.30, 95% CI: 0.07, 0.53), while exposure to The Real Cost smoking prevention ads did not affect smoking-related outcomes compared with control (p-values > .05). Turning to spillover effects, exposure to The Real Cost smoking prevention ads led to less susceptibility to vaping (d = -0.34, 95% CI: -0.56, -0.12), more negative attitudes toward vaping (d = 0.43, 95% CI: 0.20, 0.65) and higher perceived likelihood of harm from vaping (d = 0.26, 95% CI: 0.04, 0.48), compared with control. Exposure to The Real Cost vaping prevention ads did not affect smoking-related outcomes compared with control (p-values > .05).

CONCLUSIONS

This experiment found evidence of beneficial spillover effects of smoking prevention ads on vaping outcomes and found no detrimental effects of vaping prevention ads on smoking outcomes.

IMPLICATIONS

Little research has examined the spillover effects of tobacco communication campaigns, such as how anti-smoking ads affect vaping. Using a national sample of 623 U.S. adolescents, we found beneficial evidence of spillover effects of smoking prevention ads on vaping outcomes, which is promising since it suggests that smoking prevention campaigns may have the additional benefit of reducing both smoking and vaping among adolescents. Additionally, we found that vaping prevention campaigns did not elicit unintended consequences on smoking-related outcomes, an important finding given concerns that vaping prevention campaigns could drive youth to increase or switch to using combustible cigarettes instead of vaping.

Adolescents' Understanding of Smoking and Vaping Risk Language: Cognitive Interviews to Inform Scale Development

INTRODUCTION

Perceived message effectiveness (PME) is a common metric to understand receptivity to tobacco prevention messages, yet most measures have been developed with adults. We examined adolescents' interpretation of language within candidate items for a new youth-targeted PME measure using cognitive interviewing. We sought to understand the meaning adolescents assigned to our candidate PME items to improve item wording.

AIMS AND METHODS

Participants were 20 adolescents, ages 13-17 years from the United States. Cognitive interviews used a structured guide to elicit feedback on comprehension, answer retrieval, and language regarding a set of Reasoned Action Approach-based survey items that assessed the PME of smoking and vaping prevention ads. We employed thematic analysis to synthesize findings from the interviews.

RESULTS

Interviews identified three main issues related to survey items: ambiguity of language, word choice (risk and other terminology), and survey item phrasing. Adolescents preferred direct, definitive language over more ambiguous phrasing which they saw as less serious (eg, "will" instead of "could"). For risk terminology, they preferred terms such as "harmful" and "dangerous" over "risky," which was viewed as easy to discount. The term "negative effects" was interpreted as encompassing a broader set of tobacco harms than "health effects." Adolescents said that the term "vape" was preferable to "e-cigarette," and identified ways to simplify item wording for greater clarity.

CONCLUSIONS

Tobacco risk terms that appear similar differ in meaning to adolescents, and more direct and unambiguous language is preferred. Our findings informed changes to the PME scale items to improve clarity and reduce measurement error.

IMPLICATIONS

This study adds to the literature on how adolescents interpret tobacco prevention language. Adolescents may interpret terminology differently than adults, which could lead to ambiguity in meaning and thus measurement error. Through cognitive interviewing, we identified and improved the language in a youth-focused PME measure for tobacco and vaping prevention.

Impact of Vaping Prevention Advertisements on US Adolescents: A Randomized Clinical Trial

Importance

Understanding whether prevention advertisements reduce susceptibility to vaping is important owing to concerning levels of adolescent vaping.

Objective

To examine whether vaping prevention advertisements from the US Food and Drug Administration (FDA) national Real Cost campaign lead to lower susceptibility to vaping among adolescents.

Design, Setting, and Participants

For this 3-group randomized clinical trial with parallel assignment, participants were US adolescents aged 13 to 17 years who were susceptible to vaping or current e-cigarette users, recruited from online panels. Adolescents were randomized to 1 of 2 Real Cost vaping prevention trial groups (health harms- or addiction-themed advertisements) or to a control group (investigator-created neutral videos about vaping). Adolescents completed 4 weekly online surveys at visits 1 to 4 over a 3-week period. Data were analyzed from December 1, 2021, to August 25, 2022.

Interventions

Adolescents saw 3 randomly ordered 30-second video advertisements online at each of 3 weekly study visits (visits 1, 2, and 3).

Main Outcomes and Measures

The primary trial outcome was susceptibility to vaping. Surveys also assessed susceptibility to smoking cigarettes to examine any spillover effects of vaping prevention advertisements on smoking outcomes. Both susceptibility measures had 3 items and ranged from 1 (indicating not susceptible) to 4 (indicating highly susceptible). The primary analyses compared Real Cost groups (combined) with the control group, while exploratory analyses compared the Real Cost groups with each other.

Results

Participants were 1514 adolescents (1140 [75.3%] boys; mean [SD] age, 15.22 [1.18] years), including 504 randomized to the Real Cost health harms group, 506 randomized to the Real Cost addiction group, and 504 randomized to the control group. Adolescents in the Real Cost groups (combined) had lower susceptibility to vaping at visit 4 than those in the control group (b = -0.21; 95% CI, -0.32 to -0.10). The Real Cost groups did not differ from one another on susceptibility to vaping (visit 4: b = -0.05; 95% CI, -0.17 to 0.07). Adolescents in the Real Cost groups (combined) also had lower susceptibility to smoking cigarettes than those in the control group (b = -0.21; 95% CI, -0.32 to -0.10). For both vaping and smoking, Real Cost groups had less positive attitudes (vaping: b = -0.27; 95% CI, -0.40 to -0.14; smoking: b = -0.23; 95% CI, -0.39 to -0.08) compared with the control group.

Conclusions and Relevance

These findings suggest that vaping prevention advertisements from the FDA Real Cost campaign led to lower adolescent susceptibility to vaping and had beneficial spillover effects on cigarette smoking outcomes. Tobacco prevention campaigns can help reduce youth tobacco use.

Trial Registration

ClinicalTrials.gov Identifier: NCT04836455.

Textual and pictorial enhancement of cannabis warning labels: An Online experiment among at-risk U.S. young adults

BACKGROUND

This study experimentally examines whether enhanced cannabis warning labels (CWLs) outperform those currently required in the U.S. in improving recall of health risks, emotional responses, and perceived message effectiveness among at-risk young adults.

METHOD

We conducted an online national survey-based experiment in October 2020. Young adults aged 18-26 years old and at-risk for cannabis use (N = 523) were randomly assigned in an online experiment, to view either currently required CWLs in California with small font and a composite health risk statement, or enhanced single-theme CWLs with varying textual and pictorial components. We performed linear regression analyses to compare the enhanced with existing CWLs on information recall, negative emotions, and perceived message effectiveness. Furthermore, information recall and negative emotions were examined as parallel mediators to better understand the mechanisms underlying effective textual and pictorial enhancement of CWLs.

RESULTS

Compared with currently required CWLs in California, both textually (b = 0.30, p = .011) and pictorially (b = 0.59, p < .001) enhanced CWLs increased recall accuracy. Pictorially enhanced CWLs outperformed their text-only counterparts (b = 0.28, p = .019) in improving information recall. Only pictorially enhanced CWLs improved perceived message effectiveness (b = 0.31, p = .008), which was mediated by negative emotions but not by information recall.

CONCLUSIONS

Given rapid expansion of the cannabis industry and declining perception of harm, currently required CWLs in the U.S. such as California's, would benefit from redesign to improve public understanding of health risks and to prevent youth use.

Message Source Credibility and E-Cigarette Harm Perceptions among Young Adults

This study examined the effect of message source credibility on e-cigarette harm perceptions among U.S. young adults. An online experimental study was conducted where young adults (n = 302, Mage = 23.7) were randomized to an e-cigarette public health education message from an expert or a peer young adult. Then, participants answered questions about their perceptions about the message source and e-cigarettes. Results suggest that young adults rated experts as a more credible source (vs. peer) (b = −0.39, SE = 0.15, 95% CI [−0.67, −0.10], p < 0.01). Young adults reported greater perceived credibility of the expert message (vs. peer), which was associated with increased e-cigarette harm perceptions. Increased perceived source credibility mediated the association of increased e-cigarette absolute harm perceptions from viewing an expert message (b = −0.11, SE = 0.04, 95% CI: −0.20, −0.02). Source credibility should be considered when designing e-cigarette education messages for young adults.

Perceived communication effectiveness in implementation strategies: a measurement scale

BACKGROUND

Communication-based activities and products (i.e., training programs, webinars) are a critical component of implementation strategies that relay information to various audiences. Audience perceptions of communication effectiveness contribute important insight into the processes and mechanisms through which an implementation effort may succeed or fail. To advance research on this front, a psychometrically sound instrument for measuring perceived communication effectiveness (PCE) is needed.

METHODS

An expert panel identified the theoretical foundations and conceptual domains of PCE and drafted preliminary items. Five focus groups of correctional professionals who had recently completed an implementation leadership training reviewed the items and provided feedback for refinement. Revised items were then included in a survey-based evaluation of an ongoing eLearning curriculum designed to improve the practices used by front-line probation officers in supervising individuals in the field. The factorial structure of a final 6-item scale as well as its convergent, divergent, and predictive validity was evaluated using data from the evaluation surveys (Nfollow-up = 358, Nbaseline+follow-up = 159).

RESULTS

Confirmatory factor analysis of the final scale of PCE demonstrated adequate fit. PCE was strongly correlated with measures of implementation outcomes (acceptability, r = .819, p < .001; appropriateness, r = .809, p < .001; and feasibility, r = .754, p < .001), yet uncorrelated with a scale of need to evaluate (r = - .051, p = .422), demonstrating both convergent and divergent validities. The predictive validity of PCE was evidenced by significant associations between PCE and key training outcomes, including perceived staff use of evidence-based practices (β = .230, p < .05), agency climate (β = .261, p < .05), and value concordance (β = .209, p < .05), after controlling for baseline values and other confounders.

CONCLUSIONS

The PCE scale is psychometrically sound and can be a useful tool for gauging audience receptivity to and the potential impact of communication-based implementation activities and products.

Optimising tobacco control campaigns within a changing media landscape and among priority populations

Reviews published over the past decade confirm tobacco control campaigns can be effective for influencing adult and youth tobacco use behaviours, with strengthening evidence for high cost-effectiveness. Evidence is also accumulating for positive campaign effects on interpersonal discussions, social norms and policy support that can help motivate and sustain quitting and reduce uptake. Research needs over the next decade centre on the rapidly changing media environment and the equity of campaign effects among high smoking prevalence communities. The field needs specific evidence on: how to measure total campaign reach and frequency across the diverse range of media platforms and channels; the optimum mix of traditional, digital and social media to achieve behaviour change, especially among high smoking prevalence communities; the relative reach and impact of the wide variety of integrated, digital and social media message delivery methods; the relative effectiveness of messages that aim to build capacity to quit and optimum methods for combining motivational and capacity-building messages, especially for high prevalence groups who face additional barriers to staying quit; the ongoing effectiveness of traditional versus new versions of messages highlighting tobacco industry practices; the influence of e-cigarette use on tobacco control campaign effects; and the effectiveness of different types of campaigns aiming to prevent e-cigarette uptake and motivate e-cigarette cessation. Research is also needed to investigate the potential for campaigns to influence the public's understanding and support for endgame tobacco control policies and for campaign elements that may influence the social and environmental contexts surrounding smokers that support and maintain behaviour change.

Influence of the San Francisco, CA, Sugar-Sweetened Beverage Health Warning on Consumer Reactions: Implications for Equity from a Randomized Experiment

BACKGROUND

In 2020, San Francisco, CA, amended an ordinance requiring warning labels on advertisements for sugary drinks to update the warning message. No studies have evaluated consumer responses to the revised message.

OBJECTIVES

To evaluate responses to the 2020 San Francisco sugary drink warning label and to assess whether these responses differ by demographic characteristics.

DESIGN

Randomized experiment.

PARTICIPANTS AND SETTING

During 2020, a convenience sample of US parents of children aged 6 months to 5 years (N = 2,160 included in primary analyses) was recruited via an online panel to complete a survey. Oversampling was used to achieve a diverse sample (49% Hispanic/Latino[a], 34% non-Hispanic Black, and 9% non-Hispanic White).

METHODS

Participants were randomly assigned to view a control label ("Always read the Nutrition Facts Panel") or the 2020 San Francisco sugary drink warning label ("SAN FRANCISCO GOVERNMENT WARNING: Drinking beverages with added sugar(s) can cause weight gain, which increases the risk of obesity and type 2 diabetes."). Messages were shown in white text on black rectangular labels.

MAIN OUTCOME MEASURES

Participants rated the labels on thinking about health harms of sugary drink consumption (primary outcome) and perceived discouragement from wanting to consume sugary drinks. The survey was available in English and Spanish.

STATISTICAL ANALYSES PERFORMED

Ordinary least squares regression.

RESULTS

The San Francisco warning label elicited more thinking about health harms (Cohen's d = 0.24; P < 0.001) than the control label. The San Francisco warning label also led to more discouragement from wanting to consume sugary drinks than the control label (d = 0.31; P < 0.001). The warning label's influence on thinking about harms did not differ by any participant characteristics, including age, gender, race/ethnicity, education, income, or language of survey administration (all P values for interactions > 0.12).

CONCLUSIONS

San Francisco's 2020 sugary drink warning label may be a promising policy for informing consumers and encouraging healthier beverage choices across groups with diverse demographic characteristics.

Storybooks About Healthy Beverage Consumption: Effects in an Online Randomized Experiment With Parents

INTRODUCTION

Parents spend substantial time reading to their children, making storybooks a promising but understudied avenue for motivating parents to serve their children healthier beverages. This study examines parents' reactions to messages promoting healthy beverage consumption embedded in a children's storybook.

METHODS

In 2020, a total of 2,164 demographically diverse parents of children aged 6 months to 5 years participated in an online survey. Participants were randomized to view control messages (school readiness) or 1 of 3 beverage message topics (sugary drink discouragement, water encouragement, or combined discouragement and encouragement) presented as pages from the storybook Potter the Otter. Survey items assessed parents' reactions to the messages and their perceptions, beliefs, and intentions regarding sugary drinks and water. Data were analyzed in 2021.

RESULTS

Compared with control messages, exposure to the beverage messages led to higher discouragement from serving children sugary drinks and higher encouragement to serve children more water (p<0.001). The beverage messages also elicited more thinking about beverages' health impacts and led to stronger perceptions that sugary drinks are unhealthy (p<0.001). Moreover, the beverage messages led to higher intentions to limit serving children sugary drinks and higher intentions to serve children more water (p≤0.02). Parents' reactions to the beverage messages did not differ by most demographic characteristics. Few differences in outcomes were observed among the 3 beverage message topics.

CONCLUSIONS

Embedding beverage messages in storybooks is a promising, scalable strategy for motivating parents from diverse backgrounds to serve children more water and fewer sugary drinks.

Factors Associated with E-Cigarette Quit Intention Among Adolescents in the United States

Background: Given increasing use of e-cigarettes among adolescents in the United States and its potential for nicotine addiction, encouraging adolescents to quit using these products has become a public health priority. This study examined factors at various socio-ecological levels associated with e-cigarette quit intention (pre-contemplation, contemplation, or preparation) using the Stages of Change of the Trans-theoretical Model among the U.S. adolescents. Methods: We used cross-sectional data from the past 30-day adolescent exclusive e-cigarette users participating in Wave 4 of the Population Assessment of Tobacco and Health study (n = 349). Weighted adjusted multinomial logistic regression models were used to analyze the data. Results: Compared to pre-contemplators and contemplators, preparators were more likely to believe that nicotine in e-cigarettes was "very/extremely harmful" (vs. "not at all harmful") to health (p < 0.001) and people cause a "lot of harm" (vs. "no harm") to themselves when they use e-cigarettes (p < 0.001). In comparison to pre-contemplators, contemplators and preparators were more likely to report that their parents/guardians talked with them about not using e-cigarettes than those whose parents/guardians did not talk with them (p < 0.001). Additionally, contemplators and preparators were also more likely to report that they "often/very often" (vs. never) noticed health warnings on e-cigarette packages (p < 0.001). Conclusion: Our findings suggest that harm perception, influence of family, and e-cigarette health warnings are some of the important factors associated with the stages of change for intention to quit among adolescent e-cigarette users. This study will help public health practitioners and researchers design multi-level e-cigarette cessation interventions for adolescents.

Does the content and source credibility of health and risk messages related to nicotine vaping products have an impact on harm perception and behavioural intentions? A systematic review

AIMS

To systematically review the literature on (i) whether and how various risk messages about nicotine vaping products (NVPs) alter harm perception and behavioural intentions of smokers and non-smokers and (ii) how trust in sources of NVP risk communication affects message reception and behavioural intentions.

METHODS

Seven electronic databases and reference lists of relevant articles were searched for articles published up to April 2020. Experimental and quasi-experimental studies on message effects and cross-sectional studies on source credibility were included. The Newcastle-Ottawa Scale and the Evidence Project Risk of Bias Tool were used to assess the quality of observational and intervention studies, respectively. For each outcome variable, we indicated whether there was an effect (as a 'yes' or 'no') and used effect direction plots to display information on the direction of effects.

RESULTS

Nicotine addiction messages resulted in greater health and addiction risk perceptions, relative risk messages comparing the health risks of NVPs to cigarette smoking increased the perception that NVPs are less harmful than combustible cigarettes, and a nicotine fact sheet corrected misperceptions of nicotine and NVPs. Smokers' intention to purchase, try or switch to NVPs was higher when exposed to a relative risk message and lower when exposed to nicotine addiction warnings. Trust in NVP risk information from public health agencies was associated with lower odds of; (i) NVP use and (ii) perceiving NVPs as less harmful, whereas those who trusted information from NVP companies were more likely to perceive NVPs as less harmful than combustible cigarettes.

CONCLUSIONS

Relative risk messages may help improve the accuracy of harm perceptions of nicotine vaping products and increase smokers' intentions to quit smoking and/or to switch to vaping, although the literature is nascent.

Message Fatigue to Bystander Intervention Messages: Examining Pathways of Resistance among College Men

Bystander intervention programs are a feature on college campuses; however, the effectiveness of these programs among certain subsets of men has recently been questioned. The current study examines college men's resistance to bystander intervention efforts by investigating message fatigue as a theoretical explanation for how bystander intervention programs may fail among college men. Specifically, the current study examined both active (i.e., reactance) and passive (i.e., inattention) resistance to bystander intervention messages among a sample of college men (N = 518). Results were consistent with reactance as a mediating mechanism explaining message failure among fatigued audiences. The mediating role of inattention was not supported. Theoretical and practical implications of the current study are discussed.

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.

Identifying message content to reduce vaping: Results from online message testing trials in young adult tobacco users

INTRODUCTION

Young adults' e-cigarette use is associated with perceptions that e-cigarettes are less harmful or addictive than cigarettes, socially acceptable, and appealing. This study developed and tested vaping educational messages addressing these factors: 1) Harm Perceptions, 2) Addictiveness, 3) Social Use, and 4) Flavors.

METHODS

Two message trials were conducted in U.S. Amazon Mechanical Turk workers aged 18-24 using a 2 (content: addiction, harm) × 3 (theme: alone, + flavors, + social) design with multiple messages in each of the six categories. Participants were assigned to view a random subset of messages and report on likeability and perceived message effectiveness (PME). Phase 1 (n = 200) tested 33 messages and 32 images. Phase 2 (n = 769) tested combinations of Phase 1's 24 most effective messages with 6 images rated most likeable or effective. Linear mixed effects models assessed the effect of content, theme, image, and their interactions on message response.

RESULTS

In both trials, most participants were past 30-day tobacco users. Harm content messages produced higher PME ratings than addiction content messages, and flavor theme messages were correlated with higher likeability scores than "content alone" theme messages. In Phase 2, flavor and social message themes decreased the PME of harm messages. There was no effect of images on either outcome controlling for the independent or interaction effects of content, theme, and image.

CONCLUSIONS

Messages conveying the harms of vaping may be best for reducing vaping in young adult tobacco users; flavor and social themes may diminish their effectiveness.

Adolescents and Young Adults Who Vape or Are Susceptible to Vaping: Characteristics, Product Preferences, and Beliefs

This study examined differences among current vapers, those susceptible to vaping, and those non-susceptible to vaping among adolescents and young adults (AYAs) in the U.S. We sought to understand vaping-related characteristics, preferences, and beliefs across these populations to inform prevention efforts. Methods: Participants were N=543 adolescents and N=557 young adults recruited in mid-2019 in the U.S. In two separate cross-sectional surveys, we assessed vaping preferences, tobacco product use, and both health harm and addiction risk beliefs about vaping. We ran separate multivariate logistic regressions to assess differences in risk beliefs across the three distinct e-cigarette groups among AYAs. Results: A majority of AYAs were either current vapers (adolescents: 32%, young adults: 36%) or susceptible to vaping (adolescents: 34%, young adults: 24%). In both samples, pod-based devices were the most common device type used, and fruit and mint/menthol were the most commonly used flavors. In multivariate analyses, adolescent (p<.05) and young adult (p<.05) current vapers both had lower risk beliefs about the health harms of vaping compared to those susceptible to vaping. Susceptible adolescents also had lower health harm risk beliefs compared to those who were non-susceptible (p<.05). Addiction risk beliefs seldom predicted use or susceptibility in multivariate analyses, with only susceptible young adults having lower addiction beliefs than those non-susceptible (p<.05). Conclusion: Results from this study highlight the role of health harm risk beliefs among AYA vapers and those susceptible to vaping. Prevention efforts should examine the most potent ways to communicate vaping health harms to discourage AYA vaping.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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