Youth Receptivity to FDA's The Real Cost Tobacco Prevention Campaign: Evidence From Message Pretesting

Associations of educational and marketing messages with beliefs about nicotine and reduced nicotine cigarettes

INTRODUCTION

Widespread misperceptions about nicotine may have unintended effects on public health. We examined associations between existing messages about nicotine or tobacco and beliefs about nicotine and reduced nicotine cigarettes (RNC).

METHODS

2962 U.S. 18-45-year-olds were randomized in a May 2022 web-based survey to view one of 26 text-based messages about tobacco or nicotine from three sources: ongoing research (n = 8), messages authorized by FDA for VLN cigarettes (n = 6), and FDA's "From Plant to Product to Puff" campaign (n = 12); six messages from FDA's campaign did not reference nicotine and were treated as the reference source. Analyses examined associations between messages, grouped by source and individually, with beliefs about nicotine and RNC addictiveness and harms.

RESULTS

Relative to FDA messages that did not reference nicotine, all message sources were associated with greater odds of a correct belief about nicotine (Odds Ratios [ORs] = 1.40-1.87, p's < 0.01); VLN messages were associated with greater correct beliefs about RNC addictiveness (b = 0.23, p < .05). No campaign produced greater correct beliefs about RNC harms. At the individual level, only five messages were associated with a correct belief about nicotine (ORs = 2.12-2.56, p-values < .01), and one with correct beliefs about RNC harms (b = 1.09, p < .05), vs. the reference message.

CONCLUSIONS

Few existing messages improved understanding of the risks of nicotine separately from the risks of combustible products. Communication research is needed to promote greater public understanding of nicotine while minimizing unintended effects on nicotine and tobacco use.

A qualitative exploration of e-cigarette prevention advertisements' effectiveness among college students in China

INTRODUCTION

The rapid growth of e-cigarette usage among youth and young people has emerged as a significant public health concern. It is imperative to initiate effective vaping prevention campaigns and undertake relevant research to address this pressing issue. This research seeks to identify effective video advertisements to deter young people from starting to use e-cigarettes. It aims to offer evidence-based insights and recommendations for creating communication materials and designing messages for youth e-cigarette prevention efforts.

METHODS

College students aged 18-24 years (n=40) participated in focus groups within this qualitative study. After viewing four stimulus videos, participants discussed what they perceived as effective and ineffective video characteristics, as well as suggestions for future videos.

RESULTS

Effective video characteristics included the use of real-life testimonials, displaying specific health hazards, revealing harmful chemical ingredients and the deceptive nature of flavors, and positively perceived effectiveness. Participants generally found that videos with strong visual impact and graphics were more engaging and that approaches using fear and emotion were more effective. Ineffective characteristics included complex and exaggerated information, lack of empathy and irrelevance, insufficiently specific information, extreme and death-themed content, industry messages, as well as preachy tones, animations, metaphors, dull formats, excessive length, and scenes of e-cigarette use.

CONCLUSIONS

Developing anti-e-cigarette campaign materials for youth necessitates target audience-focused qualitative research. This helps in deeply exploring and identifying effective themes and messages, as well as video characteristics and details while avoiding ineffective or even misleading messages and themes from young people's perspectives outside the United States. Future development of e-cigarette prevention videos for Chinese college students may consider incorporating localized real-life testimonial cases to convey specific harms, including self-efficacy information, and utilizing fear and emotional appeals.

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.

Exposure Among Middle and High School Students to Warning Labels on E-Cigarette Packages Before and After an FDA Requirement, 2018-2019

Introduction

Beginning August 10, 2018, a US Food and Drug Administration (FDA) rule required all e-cigarette packages to have a health warning. We examined exposure among middle and high school students to e-cigarette warnings before and after the compliance date of the FDA's deeming rule, a rule allowing the FDA to regulate e-cigarettes, cigars, and other products.

Methods

We analyzed data from middle and high school students participating in the 2018 and 2019 National Youth Tobacco Survey. We generated weighted prevalence estimates for any exposure ("rarely," "sometimes," "most of the time," or "always") and high exposure ("most of the time" or "always") to warnings. We used independent 2-sided t tests to examine differences in exposure between 2018 and 2019 and χ2 tests to examine differences in any exposure and high exposure by demographic characteristics and tobacco use behaviors in 2019. Analyses excluded respondents who reported they had not seen an e-cigarette package.

Results

In 2019, 68.0% (vs 67.7% in 2018) of students reported any past 30-day exposure to e-cigarette warning labels and 35.0% (vs 28.7% in 2018) reported high exposure; we observed differences in the proportion of students reporting any and high exposure to warning labels across demographic characteristics and tobacco use behaviors. From 2018 to 2019, report of any and high exposure to e-cigarette warning labels increased among students who currently used any tobacco product and e-cigarettes. We observed increases in high exposure to e-cigarette warning labels overall, and among male students, female students, non-Hispanic White students, and middle and high school students.

Conclusion

After implementation of the health warnings per the FDA's deeming rule, the percentage of current tobacco users and e-cigarette users among middle and high school students who reported any and high exposure to e-cigarette warning labels increased. Continued monitoring of reactions can inform if warnings are achieving their regulatory goal.

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.

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.

Framing Youth Vaping Prevention Messages: The Role of Uncertainty Tolerance

Vaping is the most prevalent form of tobacco use among youth in the United States. Motivated by the certainty effect in prospect theory, this study investigated the role of uncertainty tolerance as a potential moderator of the effects of gain- vs. loss-framed text messages for youth vaping prevention. Youth susceptible to future vaping (N = 536) were randomized to view a series of eight gain- or loss-framed text messages about the health consequences of vaping. Cognitive and affective responses to the messages as well as beliefs, attitude, and intentions about vaping were assessed post-exposure. Results showed an overall advantage of the loss frame on several outcomes. Additionally, an interaction between framing and uncertainty tolerance was observed for most outcomes such that the loss frame was more effective for those high in uncertainty tolerance, while the gain frame held a slight edge for those low in uncertainty tolerance. Findings from this study have implications for further engaging prospect theory in message framing research. They may also inform audience segmentation and targeted message design for youth vaping prevention efforts.

Latent Classes of Perceived Addictiveness Predict Marijuana, Alcohol, and Tobacco Use in Youth and Young Adults

Background: Mass media substance use prevention efforts target addiction perceptions in young people. This study examined youth and young adults' (YAs) perceived addictiveness across several substances and the associations between addiction perceptions and substance use. Methods: Data were collected in 2019 in an online cohort study of Vermonters aged 12-25. Latent class analyses grouped participants by perceived addictiveness of nicotine, caffeine, alcohol, marijuana, cigarettes, electronic vapor products (EVPs), and opioids. Bivariate multinomial logistic and modified Poisson regression estimated associations between sociodemographics, substance use correlates, and subsequent use across latent classes. Results: Four latent classes captured addiction perceptions: high perceived addictiveness of EVPs, cigarettes, marijuana, and alcohol (Class 1: n = 317; 31.3%), low perceived addictiveness of marijuana, alcohol, and caffeine (Class 2: n = 151; 14.3%), low perceived addictiveness of marijuana (Class 3: n = 581; 46.5%), and low perceived addictiveness of nicotine, cigarettes, and EVPs (Class 4: n = 83; 7.9%). For each year increase in age, there was a 36% increased likelihood of being in Class 2 (vs. Class 1) and a 148% increased likelihood of belonging to Class 3 (vs. Class 1). Low perceived addictiveness classes were associated with ever and past 30-day marijuana and alcohol use and predicted past 30-day alcohol use at three-month follow-up. Membership in Classes 2 and 3 also predicted past 30-day marijuana use at Wave 3. Discussion: The strong association between age and latent classes defined by low perceived addictiveness suggests age group differences in addiction perceptions. Findings suggest that YAs may benefit from prevention messaging on addictiveness.

Smoking and healthcare expenditure reductions associated with the California Tobacco Control Program, 1989 to 2019: A predictive validation

BACKGROUND

Previous research used data through 2008 to estimate a model for the effect of the California Tobacco Control Program (CTCP) that used cumulative real per capita tobacco control expenditure to predict smoking behavior (current adult smoking prevalence and mean cigarette consumption per current smoker). Predicted changes in smoking behavior due to the CTCP were used to predict its effect on health care expenditure. This research updates the model using the most recently available data and estimates CTCP program effect through 2019.

METHODS

The data used in the previous research were updated, and the original model specification and a related predictive forecast model were re-estimated. The updated regression estimates were compared to those previously published and used to update estimates of CTCP program effect in 2019 dollars.

RESULTS

There was no evidence of structural change in the previously estimated model. The estimated effect of the CTCP program expenditures on adult current smoking prevalence and mean consumption per adult current smoker has remained stable over time. Over the life of the program, one additional dollar per capita of program expenditure was associated with a reduction of current adult smoking prevalence by about 0.05 percentage point and mean annual consumption per adult current smoker by about 2 packs. Using updated estimates, the program prevented 9.45 (SE 1.04) million person-years of smoking and cumulative consumption of 15.7 (SE 3.04) billion packs of cigarettes from 1989 to 2019. The program produced cumulative savings in real healthcare expenditure of $544 (SE $82) billion using the National Income and Product Accounts (NIPA), and $816 (SE $121) billion using the Center for Medicare and Medicaid Services (CMS) measure of medical costs. During this time, the CTCP expenditure was $3.5 billion.

CONCLUSION

A simple predictive model of the effectiveness of the CTCP program remained stable and retains its predictive performance out-of-sample. The updated estimates of program effect suggest that CTCP program has retained its effectiveness over its 31-year life and produced a return on investment of 231 to 1 in direct CMS medical expenditure.

Creating More Effective Vape Education Campaigns: Qualitative Feedback from Teens in Nine U.S. States

Background: Successful media campaigns to reduce teen cigarette smoking indicate a similar approach may work for vaping, though message testing research is necessary to identify effective topics and approaches. Leveraging data from message testing studies across nine U.S. states, we identify promising topics and approaches and explore how the COVID-19 pandemic affected teens' reactions to vape education commercials. Methods: Teens ages 13-18 (N = 337) who vaped or were susceptible nonusers participated in focus groups and interviews (2018-2021) to review 35 creative concepts and commercials for Behind the Haze (BTH), a vaping education campaign. After viewing each video, participants assessed its perceived effectiveness (PE) and discussed their reactions. We conducted a reflexive thematic analysis of transcripts to identify crosscutting themes and compared PE scores for each video. Results: Key features of effective commercials included detailed facts accompanied by explanatory visuals, metaphors, and empathy. Promising topics included chemicals, physical consequences, and mental health, while addiction and industry deception messages were less impactful. The pandemic drew attention to mental health and immunity messages. Impact of one's vaping on friends emerged as a promising topic. Conclusions: While some tactics from successful cigarette prevention campaigns apply to vaping, others like anti-industry messaging do not. Fact-focused messaging on chemicals, physical consequences, and mental health accompanied by impactful graphics and attention-grabbing twists should be the focus of vape education campaigns. Frequent message testing research such as that conducted to inform BTH is necessary to identify promising and sometimes unexpected messaging approaches for timely and relevant teen vaping education materials.

Effects of Vaping Prevention Messages on Electronic Vapor Product Beliefs, Perceived Harms, and Behavioral Intentions among Young Adults: A Randomized Controlled Trial

Youth have been the focus of electronic vapor product (EVP) prevention efforts though young adults had similar increases in current EVP use from 2015-2019. This study tested messages to reduce EVP use in young adults. Eight messages on vaping related harms and addictiveness combined with themes on social use and flavors were selected for inclusion in an online randomized controlled trial. Vermont young adults aged 18-24 (n = 569) were randomized to view the eight vaping prevention messages (n = 295) or eight messages on sun safety (n = 274). After completing baseline measures, participants viewed study messages and completed measures on message perceptions and perceived message effectiveness (PME), EVP-related beliefs, and EVP-related harm perceptions. Participants completed EVP-related beliefs and harm perception measures again at 1-month follow-up, as well as measures on tobacco and EVP-related behavioral intentions and behavior (ever and past 30-day use). Intervention participants reported positive impacts on vaping-related message responses. However, findings suggested no effect of vaping prevention messages on EVP-related beliefs, harm perceptions, or behaviors in the full sample. Exploratory analyses in the intervention condition showed that greater PME was associated with lower odds to intent to try cigarettes in the next year at follow-up.

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.

Evaluating the Immediate Impact of Graphic Messages for Vaping Prevention among Black and Latino Adolescents: A Randomized Controlled Trial

The purpose of this pilot study was to assess the immediate impact of vaping prevention graphic messages on the susceptibility to future vaping among Black and Latino adolescents (ages 12 to 17). Graphic messages (available in English and Spanish) were developed using participatory research procedures with Black and Latino adolescents. Recruitment was conducted by a team of diverse, bilingual (English and Spanish), trained recruiters. Participants (n = 362) were randomized in a 1:1:1:1 schema to receive one of four graphic messages (health rewards, financial rewards, autonomy, and social norms). Overall, all graphic messages but one showed a slight decrease in the number of participants susceptible to future vaping, though none of these differences was statistically significant. The graphic message on health rewards decreased the number of participants susceptible to future vaping the most (55.7% vs. 50%, at pre- vs. post-viewing, p = 0.125), followed by the graphic messages on social norms and autonomy (55.1% vs. 52.8%, p = 0.687; 55.4% vs. 52.2%, p = 0.435; respectively). The graphic message on financial rewards increased the number of participants susceptible to future vaping slightly (52.7% vs. 53.8%, p = 1.00). Future research is needed to evaluate susceptibility to future vaping before and after exposure to different and/or repeated vaping prevention graphic messages.

Exploring Definitions of "Addiction" in Adolescents and Young Adults and Correlation with Substance Use Behaviors

(1) Background: Young people engage in addictive behaviors, but little is known about how they understand addiction. The present study examined how young people describe addiction in their own words and correlations between their definitions and substance use behaviors. (2) Methods: Young adults (n = 1146) in the PACE Vermont Study responded to an open-ended item “what does “addiction” mean?” in 2019. Responses were coded using three inductive categories and fifteen subcategories. Quantitative analyses examined correlations between addiction theme definitions, demographics, and substance use behaviors. (3) Participants frequently defined addiction by physiological (68%) and psychological changes (65%) and less by behavioral changes (6%), or all three (3%); young adults had higher odds of defining addiction as physiological or behavioral changes than adolescents. Participants who described addiction as “psychological changes” had lower odds of ever electronic vapor product use (OR 0.75, 95% CI 0.57−1.00) than those using another definition, controlling for age and sex. (4) Perceptions of addiction in our sample aligned with existing validated measures of addiction. Findings discriminated between familiar features of addiction and features that may be overlooked by young adults. Substance users may employ definitions that exclude the symptoms they are most likely to experience.

Influencing adolescents’ attitudes towards nicotine products: A systematic review

Background and aim: Use of nicotine can harm adolescents’ brains and increase risk for future addiction to other drugs. Several international studies show that an acceptable attitude towards nicotine products increases the initiation or use of the products. Adolescents have limited or distorted knowledge about nicotine products. Many of them have a positive image of the properties and effects of nicotine products, which increases the chances of smoking or using snus. Yet, we know little about the relationship between youth nicotine use, youth attitudes towards nicotine products and the interventions to influence these attitudes. This systematic review synthesised adolescents’ attitudes towards nicotine products and the ways to influence them. Methods: Systematic searches were carried out from PubMed, MEDLINE, CINAHL, and MEDIC databases and were targeted to randomised controlled trial (RCT) studies published in 2010–2021. Results: A total of seven RCT studies were reviewed with a total population (age range 9–17 years, adolescents 11–17 years) of 15,974. Findings were classified into four categories: school-based interventions, tobacco prevention campaigns, advertisements’ influence on adolescents’ opinions towards nicotine products, and their responses to cigarette pack warnings. Conclusion: Based on this systematic literature review, particularly school-based interventions have an effect on adolescents’ attitudes towards smoking and preventing them from starting to smoke, when they are targeted before the age of puberty. School-based interventions should be further implemented and strengthened, as the school has been shown to have significant potential to support youth’s health. There is a need for further information about the most effective interventions in the different age groups and the qualitative studies on the topic.

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 (N_follow-up = 358, N_{baseline+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.

Perceived Message Effectiveness and Campaign-Targeted Beliefs: Evidence of Reciprocal Effects in Youth Tobacco Prevention

Perceived message effectiveness (PE) has been widely used in campaign formative research and evaluation. The relationship between PE and actual message effectiveness (AE) is often assumed to be causal and unidirectional, but careful conceptualization and empirical testing of this and other causal possibilities are generally lacking. In this study, we investigated the potential reciprocity in the relationship between PE and AE in the context of a national youth tobacco education campaign. In so doing, we also sought to generate much needed evidence on PE's utility to predict campaign-targeted outcomes in youth tobacco prevention. Using five waves of campaign evaluation data (N = 1,128), we found significant lagged associations between PE and campaign-targeted beliefs, and vice versa. These results suggest a dynamic, mutually influencing relationship between PE and AE and call for greater attention to such dynamics in campaign research.

Responses to e-cigarette health messages among young adult sexual minoritized women and nonbinary people assigned female at birth: Assessing the influence of message theme and format

BACKGROUND

Young adult sexual minority women (YSMW) report disproportionate e-cigarette (EC) use and low EC harm perceptions. Health messages that effectively communicate EC harms to YSMW are needed. We tested the effect of culturally targeted EC health messages with varying themes and image formats on attitudes and intentions to use ECs in this population.

METHODS

N = 501 YSMW and nonbinary people assigned female at birth (AFAB) aged 18-30 years-old completed an online experiment. Participants were randomized into a control or one of nine experimental conditions in a 3 (theme: harms, wellness, pride) by 3 (image format: individual, couple, cartoon) study design. We modeled associations between message condition and message effectiveness, discouragement from vaping, change in feelings toward vaping, perceived threat, and intentions to abstain from vaping.

RESULTS

Among YSMW and nonbinary people AFAB, harm and wellness themes discouraged vaping more than pride-themed messages (p's < 0.001). Harms messages resulted in worse feelings about vaping than wellness and pride messages (p's < 0.02). Images of couples were perceived as more effective than cartoon images (p = .008). Among current EC users, viewing images of individuals resulted in greater readiness to avoid ECs and higher intentions to abstain than the couple or cartoon conditions (p's < 0.001).

CONCLUSIONS

Message theme and image format were associated with YSMW and nonbinary people AFAB's EC attitudes and behavioral intentions. Future studies should evaluate how to optimize harms messages; including if wellness or pride messages can be re-framed to better affect EC use in this population.

Minoritized Sexual Identity and Perceived Effectiveness of Instagram Public Health Messaging about E-cigarettes

E-cigarette (EC) use in young adult sexual-minoritized women (SMW) is disproportionately higher than among heterosexual women and sexual-minoritized men. Public health messaging utilizing social branding, a method used to tailor health messages to one's identity, may help combat this problem. We conducted an online study with SMW (N= 457) and asked them to complete scales assessing their sexual minoritized identity affirmation and centrality. Participants were randomized to view socially branded messages discouraging EC use across three themes (general wellness, pride, health harms). Results revealed that overall lesbian, bisexual, or queer (LBQ) identity (affirmation and centrality) was significantly positively associated with perceived message effectiveness (PME) (p < .001). Identity affirmation was significantly associated with PME when controlling for identity centrality (p = .004). Interaction between identity affirmation and theme was significant (p= .02), as positive effects of identity affirmation on PME were greater when participants viewed pride-themed messages versus wellness (p= .03) or harms messages (p = .01). The findings suggest that socially branded EC prevention messages emphasizing sexual minoritized identity may be more effective for SMW with a strong connection to their LBQ identity. Future research should examine how identity and socially branded messages can impact health behaviors.

Age of Onset of Susceptibility to Different Tobacco Products Among Non-Susceptible US Young Adults: Findings from the Population Assessment of Tobacco and Health Study Waves 2-4 (2014-2017)

INTRODUCTION

Initiation of tobacco products is increasing in young adulthood. This study prospectively estimated the age of onset of susceptibility to cigarettes, e-cigarettes, hookah, smokeless tobacco, and cigarillos among young adults, which is a cognitive precursor to initiation.

METHODS

Secondary data analyses of the Population Assessment of Tobacco and Health (PATH) study, a nationally representative longitudinal cohort study of US adults. Young adults (18-24 years) who were non-susceptible to each tobacco product (cigarettes, e-cigarettes, hookah, smokeless tobacco, and cigarillos) at waves 2 or 3 were followed-up into waves 3-4 to prospectively estimate the age of onset of susceptibility to each tobacco product. Weighted interval-censored survival methods and interval-censored Cox regression models were implemented to estimate the age of onset of susceptibility, and to estimate differences in the hazard function by sex and by race/ethnicity, while controlling for the total number of other tobacco products ever used at their first wave of participation in PATH.

RESULTS

By age 21, 16.5%, 16.0%, 12.6%, 12.4%, and 5.9% of young adults reported onset of susceptibility to hookah, e-cigarettes, cigarillos, cigarettes, and smokeless tobacco, respectively. Among young adults who were non-susceptible to each tobacco product at waves 2 or 3, the highest increase in onset of susceptibility occurred between ages 18 and 19 for cigarettes, e-cigarettes, and hookah, while the highest increase in onset of susceptibility occurs between ages 22 and 23 for cigarillos. Young adult males had increased risk of onset of susceptibility to cigarillos and smokeless tobacco at earlier ages than young adult females. Differences in onset of susceptibility to each tobacco product were also observed by race/ethnicity among young adults.

CONCLUSIONS

With the changing landscape of tobacco products, monitoring the age of onset of susceptibility of tobacco product use among non-susceptible young adults longitudinally is critical to prevent initiation. Communication and education campaigns tailored to address differences in susceptibility among young adults by tobacco product and sociodemographic factors will be useful.

Optimizing Images for an E-Cigarette Messaging Campaign: Liking and Perceived Effectiveness

Introduction: Given the prevalence of electronic vapor product (EVP) use among young people in the US, there is a need for effective vaping education campaigns. This study tested 32 images for liking and perceived effectiveness (PE) to identify optimal images for a messaging campaign. Method: Images were selected from current campaigns, warning labels, and other images based on young adult reasons for use. Images were coded for the presence of (1) people, (2) vapor, (3) device, (4) color, and (5) similarity to warning label image. Young adults (n = 200) were recruited from the Amazon Mechanical Turk platform. Participants were randomly assigned to view and rate six of the 32 images on liking as well as PE, which measured the potential impact of the image to discourage vaping appeal and use. Results: Images containing vapor and/or a device or e-liquid were not well-liked but were perceived as effective in discouraging vaping (ps < 0.05). Images from warning labels were also not well-liked but were perceived as significantly more effective than those not from a warning (p < 0.01). Liking and effectiveness of features was similar for both EVP users and non-users. Discussion: Images with specific features were rated as less likable but rated as higher on PE. However, the consistency of image features rated as effective by EVP users and non-users supports the utility of similar imagery for vaping prevention and reduction efforts.

What’s in the message? An analysis of themes and features used in vaping prevention messages

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As youth vaping grows, vaping prevention campaigns are emerging rapidly.

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Our study systematically examines prevention messages used by public health groups.

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Nicotine addiction and chemicals were the most common message themes.

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Most messages included imagery, yet just over half had a message source.

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Results can guide message testing and highlight messaging gaps.

Introduction

Federal, state, local, and non-government officials have developed and implemented a variety of vaping prevention messages to curtail the vaping epidemic among youth in the US. This study sought to collect a comprehensive set of vaping prevention messages and characterize the themes and features of those messages.

Methods

We used a two-fold search strategy to identify messages, utilizing the existing content database from Vaping Prevention Resource (vapingprevention.org) and supplementing those messages with web searches. Potential messages were included if they were vaping prevention-oriented, appropriate or relevant for youth, and in a static web or print format.

Results

A total of 220 messages met criteria. Messages were coded on the presence or absence of 37 objective features within five categories: message themes, imagery, text features, message perspective, and other (e.g., source). The most common themes were nicotine addiction (32%), chemicals (30%), health effects (24%), and industry targeting (19%). Eighty-five percent of messages included imagery, with 27% showing a vaping device, 22% showing smoke or vapor, and 21% showing a person’s face. Just over half (56%) included a message source.

Conclusions

Vaping prevention messages for youth have commonly focused on addiction and health risks of vaping, and they vary on a series of text and image features. Further research is needed to understand the efficacy of messaging approaches in preventing vaping among youth.

Integrating Self-Report and Psychophysiological Measures in Waterpipe Tobacco Message Testing: A Novel Application of Multi-Attribute Decision Modeling

BACKGROUND

Waterpipe (i.e., hookah) tobacco smoking (WTS) is one of the most prevalent types of smoking among young people, yet there is little public education communicating the risks of WTS to the population. Using self-report and psychophysiological measures, this study proposes an innovative message testing and data integration approach to choose optimal content for health communication messaging focusing on WTS.

METHODS

In a two-part study, we tested 12 WTS risk messages. Using crowdsourcing, participants (N = 713) rated WTS messages based on self-reported receptivity, engagement, attitudes, and negative emotions. In an in-lab study, participants (N = 120) viewed the 12 WTS risk messages while being monitored for heart rate and eye-tracking, and then completed a recognition task. Using a multi-attribute decision-making (MADM) model, we integrated data from these two methods with scenarios assigning different weights to the self-report and laboratory data to identify optimal messages.

RESULTS

We identified different optimal messages when differently weighting the importance of specific attributes or data collection method (self-report, laboratory). Across all scenarios, five messages consistently ranked in the top half: four addressed harms content, both alone and with themes regarding social use and flavors and one addiction alone message.

DISCUSSION

Results showed that the self-report and psychophysiological data did not always have the same ranking and differed based on weighting of the two methods. These findings highlight the need to formatively test messages using multiple methods and use an integrated approach when selecting content.

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

Perceived message effectiveness (PME) is commonly used in health communication research and practice, yet there has been a dearth of studies comparing different operationalizations of the PME construct. In the present study, we compared the two major types of PME - message perceptions and effects perceptions - among N = 557 young adults. Participants were randomized to one of two conditions: 1) The Real Cost e-cigarette prevention ads developed by the Food and Drug Administration (FDA condition) or 2) information-only e-cigarette control ads developed by the Mayo Clinic (control ad condition). Study predictors were message and effects perceptions measures and actual message effectiveness (AME) outcomes were risk beliefs about vaping and intentions to vape. Results showed that both message perceptions (M = 3.82 vs M = 3.29; p < .001) and effects perceptions (M = 4.13 vs M = 3.82; p < .001) were higher in the FDA ad condition compared to control. Risk beliefs about vaping were also higher in the FDA ad condition than control (M = 3.95 vs M = 3.79; p =.022), but we found no differences in participants' intentions to vape, which were low overall (M = 1.59 in FDA vs M = 1.58 in control). In multivariate analyses adjusting for covariates and including both types of PME, only effects perceptions (not message perceptions) were associated with risk beliefs about vaping (b =.37, p < .001) and intentions to vape (b = -.26, p < .001). Our findings advance PME research by demonstrating the differing nature of message and effects perceptions, and suggest that effects perceptions should be utilized during message pretesting.

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.

Development and Pretesting of Hookah Tobacco Public Education Messages for Young Adults

Young adults’ hookah tobacco use is fueled by misperceptions about risks, appealing flavors, and social use. We developed and pretested public education messages to prevent and reduce hookah tobacco smoking among young adults. We used a two (user status: current hookah user, susceptible never user) by two (risk content: health harms or addiction) by three (message theme: harms/addiction risk alone, harms/addiction risk flavors, or harms/addiction risk social use) design with two messages/condition (n = 12 total messages). Young adults aged 18–30 (N = 713) were randomized to 1 of 12 messages and completed measures assessing message receptivity, attitudes, and negative emotional response. Harms messages were associated with greater receptivity (p < 0.001), positive attitudes (p < 0.001), and negative emotional response (p < 0.001) than addiction messages. Messages with harm or addiction content alone were associated with greater receptivity than social use-themed messages (p = 0.058). Flavor-themed messages did not differ in receptivity from harm or addiction content alone or social use-themed messages. Messages about the health harms of hookah tobacco use resonate more with young adults than addiction risk messages. Social use-themed messages produce the lowest receptivity. These findings can guide population-based approaches to communicate hookah tobacco risks to young adults.

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.

Health communication campaigns: A brief introduction and call for dialogue

This article provides a brief introduction to health communication campaigns as an important method for health promotion. The general approach to campaign development is described and patterns of campaign effects across behavioral contexts are noted. Several high-profile campaigns in the United States are presented as examples and key learnings from each campaign are highlighted. The roles of theory, as well as major types of theories commonly used in campaign research, are also discussed. The article urges greater efforts to document and understand diverse campaign experience around the world.

Truth® ads, receptivity, and motivation to use or quit tobacco among college students

Objective: Examine receptivity and motivation to use/quit tobacco among college students after viewing Truth ads. Participants: Random sample of 10,000 college students invited to complete online survey February 2016 (8.5% response rate). Methods: Quasi-experimental. Participants (N = 854) watched four ads and answered survey items for each ad. Results: Students rated ad receptivity and decreased motivation to use tobacco higher for the Catmageddon ad than the others. Regardless of ad, men and current cigarette smokers reported lower receptivity. Younger age was associated with lower motivation to use tobacco for all ads. Tobacco users reported greater motivation to quit with the Catmageddon ad. Conclusions: College students were receptive to the Truth ads, and many indicated lower motivation to use tobacco. Men, older college students, and current cigarette smokers were less receptive to the ads, reinforcing the need to develop tailored campaigns to reach these subgroups.

Does Perceived Message Effectiveness Predict the Actual Effectiveness of Tobacco Education Messages? A Systematic Review and Meta-Analysis

Target audience ratings of the likely impact of persuasive messages, known as perceived message effectiveness (PME), are commonly used in health communication campaigns. However, applications of PME rely on a critical assumption-that is, that PME is a valid indicator of the likely effectiveness of messages. To examine the evidence supporting this assumption, we conducted a systematic review and meta-analysis of longitudinal studies in the tobacco education campaigns literature. Six longitudinal studies examining the predictive validity of PME met inclusion criteria. Results indicated that PME ratings were significantly associated with the majority of outcomes studied. In fact, each of the six studies found PME to be associated with at least one outcome, and across the six studies, PME was associated with message recall, conversations about ads, beliefs about smoking and quitting smoking, quit intentions, and cessation behavior. Meta-analyses demonstrated that PME predicted quit intentions (r = .256, p < .001) and cessation behavior (r = .201, p < .001), revealing effects that were small to medium in magnitude. Our results suggest that PME provides some predictive value as to the likely effectiveness of messages, although additional work using different validation designs, with other health behaviors, and among other populations is needed.

Message-Elicited Brain Response Moderates the Relationship Between Opportunities for Exposure to Anti-Smoking Messages and Message Recall

Campaign success is contingent on adequate exposure; however, exposure opportunities (e.g., ad reach/frequency) are imperfect predictors of message recall. We hypothesized that the exposure-recall relationship would be contingent on message processing. We tested moderation hypotheses using 3 data sets pertinent to "The Real Cost" anti-smoking campaign: past 30-day ad recall from a rolling national survey of adolescents aged 13-17 (n = 5,110); ad-specific target rating points (TRPs), measuring ad reach and frequency; and ad-elicited response in brain regions implicated in social processing and memory encoding, from a separate adolescent sample aged 14-17 (n = 40). Average ad-level brain activation in these regions moderates the relationship between national TRPs and large-scale recall (p < .001), such that the positive exposure-recall relationship is more strongly observed for ads that elicit high levels of social processing and memory encoding in the brain. Findings advance communication theory by demonstrating conditional exposure effects, contingent on social and memory processes in the brain.

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

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

Impact of The Real Cost Media Campaign on Youth Smoking Initiation

INTRODUCTION

The purpose of this study was to assess the relationship between youth exposure to the U.S. Food and Drug Administration's national tobacco public education campaign, The Real Cost, and changes in smoking initiation.

METHODS

From November 2013 to November 2016, a longitudinal study of youth was conducted with a baseline and 4 post-campaign follow-up surveys. The sample consisted of nonsmoking youths from 75 U.S. media markets (n=5,103) who completed a baseline and at least 1 follow-up survey. Exposure was measured by media market-level target rating points and self-reported ad exposure frequency. Smoking initiation was examined among youths who had never smoked at baseline and defined as first trial of a cigarette. Discrete-time survival models using logistic regression and controlling for confounding influences were estimated. Analyses were conducted in 2018.

RESULTS

The odds of reporting smoking initiation at follow-up was lower among youths in media markets with higher levels of campaign advertisements than among those with less. Both between-wave and cumulative target rating points were associated with decreased risk of smoking initiation (AOR=0.69 [p<0.01] and AOR=0.89 [p<0.05], respectively); for every 3,500 between-wave target rating points on air, there was an associated 30% reduction in the hazard of smoking initiation among youths. Results from self-reported recall of the campaign advertisements found similar dose-response effects. The campaign is associated with an estimated 380,000-587,000 youths aged 11-19 years being prevented from initiating smoking nationwide.

CONCLUSIONS

Sustained national tobacco public education campaigns like The Real Cost can change population-level smoking initiation among youths, preventing future generations from tobacco-related harms.

Reactions to electronic nicotine delivery system (ENDS) prevention messages: results from qualitative research used to inform FDA's first youth ENDS prevention campaign

Background

Youth e-cigarette use is a major public health concern. Large-scale tobacco prevention campaigns are a proven strategy to prevent tobacco use. There is a gap in understanding what types of e-cigarette prevention messages might be most effective. This study addresses this gap by reporting youth reactions to health messages aimed at preventing e-cigarette use.

Methods

In 2018, twenty-four focus groups, with 159 teens (12–17) at risk for or experimenting with e-cigarettes were conducted in four cities across the USA. During focus groups, youth responded to creative concepts dealing with (1) the addictive nature of e-cigarettes, (2) the fact that e-cigarettes come in flavours, which may encourage youth initiation, and nicotine which may lead to addiction, or (3) that youth who use e-cigarettes are more likely to use cigarettes. Youth also gave feedback to specific facts about harmful and potentially harmful chemicals in e-cigarettes. Transcripts were analysed using thematic analysis.

Results

Messages focusing on addiction alone did not resonate with participants. While youth found the idea that e-cigarettes may contain nicotine and can be addictive believable, with many describing personal experiences of addiction, they questioned how bad this really was, comparing addiction to e-cigarettes to things like being addicted to food. Participants wanted more information about negative consequences of vaping. Concepts paired with strong health effects messages resonated with participants.

Conclusion

These focus groups clarified which e-cigarette prevention messages might be most persuasive to teens. Youth in this study responded favourably to messages stating specific health consequences of e-cigarette use.

Moving beyond perceived riskiness: Marijuana-related beliefs and marijuana use in adolescents

Background: Perceived riskiness of marijuana in adolescents has been trending downward in the context of increasing legality and availability. Low perceived riskiness has been associated with marijuana use though evidence is lacking on associations among use and more specific claims about marijuana's safety and benefit, improved understanding of which could guide clinical interventions to reduce use. Methods: We analyzed cross-sectional survey data collected from 502 adolescents aged 14-18 years recruited from an urban adolescent primary care clinic. Self-report questionnaires were administered via tablet computer. Use of marijuana was assessed with a brief validated screening tool, and agreement with each of five statements about marijuana's riskiness and health properties were reported using a four-point Likert scale. We conducted multivariable logistic regressions to determine the association between perceived riskiness and other marijuana-related beliefs and past-year marijuana use. Results: In total, 149 adolescents reported past-year marijuana use (29.7%). High overall perceived risk was associated with lower rates of past-year use (AOR 0.27, 95%CI: 0.15-0.48). Agreement with positive health beliefs that "marijuana can help teenagers focus in school" and that "marijuana is safe because it's natural" were associated with past-year marijuana use (respectively, AOR 5.50, 95%CI: 3.06-9.88 and AOR 6.61, 95%CI: 3.59-12.19) while agreement with negative health beliefs that "marijuana can affect youth even after they don't feel high anymore" and that "marijuana can be addictive" were both associated with lower rates of use (AOR 0.56, 95%CI: 0.31-0.99, and AOR 0.30, 95%CI: 0.16-0.56, respectively), adjusting for sociodemographic factors and use of other substances. Conclusions: Marijuana use varied in association with beliefs about its beneficial and harmful health properties. Clinical interventions that target specific marijuana-related health beliefs including unfounded claims of benefit may provide robust talking points for centering provider guidance and public health messaging.

Considerations of Privacy and Confidentiality in Developing a Clinical Support Tool for Adolescent Tobacco Prevention: Qualitative Study

Background

Electronic clinical support tools show promise for facilitating tobacco screening and counseling in adolescent well-care. However, the application of support tools in pediatric settings has not been thoroughly studied. Successfully implementing support tools in local settings requires an understanding of barriers and facilitators from the perspective of both patients and providers.

Objective

This paper aimed to present the findings of a qualitative study conducted to inform the development and implementation of a support tool for adolescent tobacco screening and counseling in 3 pediatric clinics in North Florida. The primary objective of the study was to test and collect information needed to refine a tablet-based support tool with input from patients and providers in the study clinics.

Methods

A tablet prototype was designed to collect information from adolescents on tobacco susceptibility and use before their well-care visit and to present tobacco prevention videos based on their responses. Information collected from adolescents by the support tool would be available to providers during the visit to facilitate and streamline tobacco use assessment and counseling components of well-care. Focus groups with providers and staff from 3 pediatric clinics (n=24) identified barriers and facilitators to implementation of the support tool. In-depth interviews with racially and ethnically diverse adolescent patients who screened as susceptible to tobacco use (n=16) focused on acceptability and usability of the tool. All focus groups and interviews were audio-recorded and transcribed for team-based coding using thematic analysis.

Results

Privacy and confidentiality of information was a salient theme. Both groups expressed concerns that the tool’s audio and visual components would impede privacy and that parents may read their child’s responses or exert control over the process. Nearly all adolescents stated they would be comfortable with the option to complete the tool at home via a Web portal. Most adolescents stated they would feel comfortable discussing tobacco with their doctor. Adolescent interviews elicited 3 emergent themes that added context to perspectives on confidentiality and had practical implications for implementation: (1) purity: an expressed lack of concern for confidentiality among adolescents with no reported history of tobacco use; (2) steadfast honesty: a commitment to being honest with parents and providers about tobacco use, regardless of the situation; and (3) indifference: a perceived lack of relevance of confidentiality, based on the premise that others will “find out anyway” if adolescents are using tobacco.

Conclusions

This study informed several modifications to the intervention to address confidentiality and introduce efficiency to well-care visits. The support tool was integrated into the electronic health record system used by the study clinics and modified to offer videos to all adolescents regardless of their tobacco use or susceptibility. Future studies will further test the acceptability of the intervention in practice.

Communication Regulatory Science: Mapping a New Field

Communication regulatory science is an emerging field that uses validated techniques, tools, and models to inform regulatory actions that promote optimal communication outcomes and benefit the public. In the opening article to this special issue on communication and tobacco regulatory science, we 1) describe Food and Drug Administration (FDA) regulation of tobacco products in the US; 2) introduce communication regulatory science and provide examples in the tobacco regulatory science realm; and 3) describe the special issue process and final set of articles. Communication research on tobacco regulatory science is a burgeoning area of inquiry, and this work advances communication science, informs and potentially guides the FDA, and may help to withstand legal challenges brought by the tobacco industry. This research has the potential to have a major impact on the tobacco epidemic and population health by helping implement the most effective communications to prevent tobacco initiation and increase cessation. This special issue provides an example of 10 studies that exemplify tobacco regulatory science and demonstrate how the health communication field can affect regulation and benefit public health.

Finding Pete and Nikki: Defining the Target Audience for "The Real Cost" Campaign

Successfully reaching at-risk teens aged 12-17 years with smoking-prevention messages capable of changing their knowledge, attitudes, and beliefs about cigarette smoking requires a multifaceted approach to understand the target audience's unique demographic, environmental, behavioral, interpersonal, and intrapersonal characteristics. This paper explores the initial target audience segmentation and insights development approach used to create the underlying message strategy for "The Real Cost" youth smoking prevention media campaign-a public education effort responsible for preventing nearly 350,000 U.S. youth aged 11-18 years from initiating smoking from 2014 to 2016. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Identifying Potential Campaign Themes to Prevent Youth Initiation of E-Cigarettes

Once a target audience and a health behavior of interest are selected for a potential mass media campaign, the next task is selecting beliefs about the health behavior to serve as the basis for campaign message content. For novel health behaviors, such as the use of emerging tobacco products, limited empirical research on beliefs about these behaviors exists. A multimethod approach was applied to generate potential campaign beliefs for emerging behaviors. Three methods were conducted in this investigation in order to generate a list of potential testable campaign beliefs, using youth e-cigarette use as a case study: (1) a search of published and unpublished literature including gathering measures from several national surveys (through 2016), (2) an online elicitation survey (conducted in 2016), and (3) unsupervised topic modeling of media texts (from 2014 to 2015, analyzed in 2016). Details are provided on how each method was employed to both generate and prioritize beliefs related to youth e-cigarette use into a final set of 115 beliefs across 23 belief themes. This multimethod approach can provide four utilities when thinking through a health campaign for novel health behaviors: (1) developing an exhaustive and complementary list of beliefs, (2) generating overarching themes and distilling larger themes into more nuanced beliefs, (3) identifying language most relevant to the target population, and (4) prioritizing beliefs for message pilot testing with members of the target audience. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

A Secondary Audience's Reactions to "The Real Cost" Advertisements: Results From a Study of U.S. Young Adult Smokers and Susceptible Nonsmokers

INTRODUCTION

Exposure to "The Real Cost" campaign has prevented smoking initiation among its target audience (U.S. youth aged 12-17 years). This study examines reactions to "The Real Cost" advertisements among a potential secondary audience: U.S. young adults.

METHODS

An online convenience sample of young adult (ages 18-29 years) smokers (n=225) and susceptible nonsmokers (n=339) participated in a within-subjects experiment in 2017. Participants viewed three TV ads from "The Real Cost" campaign and reported their past exposure to, conversations about, and reactions to the ads. In 2017, analyses examined message-level and person-level predictors of perceived message effectiveness using multilevel modeling.

RESULTS

About half of smokers (47%) and susceptible nonsmokers (51%) had seen at least one of the three ads in the past 3 months. About one in four smokers (23%) and susceptible nonsmokers (24%) had at least one conversation about the ads in the past 3 months. Susceptible nonsmokers rated the ads higher on perceived message effectiveness than smokers (p<0.01), but lower on message relevance and negative affective reactions to the ads (both p<0.05). In both samples, ads that elicited higher negative affective reactions and message relevance, and lower message reactance (i.e., resistance) received higher perceived message effectiveness ratings (all p<0.05).

CONCLUSIONS

"The Real Cost" ads have reached and generated conversations among a convenience sample of young adult smokers and susceptible nonsmokers. Increasing the perceived relevance and emotional reactions of campaigns may increase their impact. Future studies should examine reactions to "The Real Cost" campaign and effects on smoking behavior using nationally representative samples of young adults.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Fear and Humor Appeals in "The Real Cost" Campaign: Evidence of Potential Effectiveness in Message Pretesting

INTRODUCTION

In tobacco prevention campaigns, fear-appeal messages are widely used and generally shown to be effective, whereas the utility of humor appeals is less clear. This study compares the potential effectiveness of fear and humor ads developed for "The Real Cost" campaign.

METHODS

Adolescents (N=1,315) aged 13-17 years who were either experimenting with smoking or susceptible to smoking initiation were randomized to view either a single ad (of three fear and two humor ads in total) or nothing (control condition). Those in the ad viewing condition completed measures on fear, amusement, and perceived ad effectiveness. All participants completed measures on smoking attitudes and risk perceptions. Data were collected in 2014 and 2015. Analysis was performed in 2016.

RESULTS

Compared with control, both fear and humor ads produced greater risk perceptions (p<0.001). Fear ads also produced more negative smoking attitudes (p=0.001); humor ads had a similar effect on attitudes that approached significance (p=0.07). Fear ads scored higher on perceived ad effectiveness and fear, and lower on amusement than humor ads (p<0.001). In regression models, fear was a stronger predictor of perceived ad effectiveness, smoking attitudes, and risk perceptions than amusement for fear ads, whereas amusement was a stronger predictor of these outcomes than fear for humor ads.

CONCLUSIONS

Both fear and humor appeals have potential to be effective in "The Real Cost" campaign. Concurrent employment of these message strategies should help to diversify messaging and consistently recapture the target audience's attention.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Lessons on Addiction Messages From "The Real Cost" Campaign

INTRODUCTION

A key strategy in reducing the public health burden of cigarette smoking is preventing youth from ever becoming addicted to cigarettes in the first place. However, there is limited research exploring youth responses to addiction messages. This study assesses youths' responses to the U.S. Food and Drug Administration's "The Real Cost" campaign messaging depicting addiction as a "loss of control."

METHODS

Between 2013 and 2016, three focus group studies and four copy testing studies were conducted to assess reactions to advertising concepts and near-final videos. Participants were aged 12-17 years and ethnically and geographically diverse. Researchers conducted a thematic secondary analysis of focus group transcripts and open-ended survey questions from the copy testing studies. Data analysis for this study took place in 2017.

RESULTS

Youth responded favorably to loss of control messages showing real, often short-term, consequences of addiction, such as choosing to spend money on cigarettes instead of going to a movie, and depictions of scenarios that were relatable to youth. Youth also responded favorably to messages describing how nicotine changes the brain. A portion of youth remained skeptical, stating they felt the consequences depicted were unrealistic.

CONCLUSIONS

This study shows that by framing addiction as a loss of control and tying that loss of control to short-term health and social consequences, addiction becomes more concrete and understandable, and the consequences feel more relatable and relevant to youth.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Fifth Anniversary Retrospective of "The Real Cost," the Food and Drug Administration's Historic Youth Smoking Prevention Media Campaign, which is sponsored by the U.S. Food and Drug Administration.

Stakeholder Engagement in Developing an Electronic Clinical Support Tool for Tobacco Prevention in Adolescent Primary Care

Following guideline recommendations to promote tobacco prevention in adolescent primary care, we developed a patient-facing clinical support tool. The electronic tool screens patients for use and susceptibility to conventional and alternative tobacco products, and promotes patient–provider communication. The purpose of this paper is to describe the iterative stakeholder engagement process used in the development of the tool. During the pre-testing phase, we consulted with scientists, methodologists, clinicians, and Citizen Scientists. Throughout the development phase, we engaged providers from three clinics in focus groups. Usability testing was conducted via in-depth, cognitive interviewing of adolescent patients. Citizen Scientists (n = 7) played a critical role in the final selection of educational content and interviewer training by participating in mock-up patient interviews. Cognitive interviews with patients (n = 16) ensured that systems were in place for the feasibility trial and assessed ease of navigation. Focus group participants (n = 24) offered recommendations for integrating the tool into clinical workflow and input on acceptability and appropriateness, and anticipated barriers and facilitators for adoption and feasibility. Engaging key stakeholders to discuss implementation outcomes throughout the implementation process can improve the quality, applicability, and relevance of the research, and enhance implementation success.

Adolescents' Aided Recall of Targeted and Non-Targeted Tobacco Communication Campaigns in the United States

We examined whether advertisements from two national tobacco control campaigns targeting adolescents (i.e., The Real Cost, Fresh Empire) and one campaign targeting adults (i.e., Tips from Former Smokers) were reaching adolescents. Data came from a national sample of adolescents aged 13 to 17 years (n = 975) surveyed by phone from August 2016 to May 2017. We assessed recall and attitudes toward five specific advertisements and three campaign slogans and examined differences by sub-groups. Almost all (95%) adolescents recalled seeing at least one campaign advertisement. Aided recall of The Real Cost and Tips from Former Smokers slogans was high (65.5% and 71.6%, respectively), while aided recall of Fresh Empire slogan was lower (15.3%) (χ² p-value: p < 0.001); however, Black adolescents had higher odds of recalling the Fresh Empire ad (aOR: 2.28, 95% CI: 1.39, 3.73) and slogan (aOR: 2.64, 95% CI: 1.06, 6.54) compared to White adolescents. Increased exposure to the advertisements (i.e., recalling more advertisements) was significantly associated with higher odds of reporting negative feelings toward tobacco products in 4/5 models (aORs from 1.34 to 1.61). Large-scale national campaigns can have wide reach among both targeted and non-targeted audiences with added benefits for cumulative cross-campaign exposure to advertisements.

Alcohol harm reduction advertisements: a content analysis of topic, objective, emotional tone, execution and target audience

BACKGROUND

Public health mass media campaigns may contribute to reducing the health and social burden attributed to alcohol consumption, but little is known about which advertising characteristics have been used, or have been effective, in alcohol harm reduction campaigns to date. As a first step towards encouraging further research to identify the impact of various advertising characteristics, this study aimed to systematically identify and examine the content of alcohol harm reduction advertisements (ads).

METHOD

Ads were identified through an exhaustive internet search of Google, YouTube, Vimeo, and relevant government and health agency websites. Eligible ads were: English language, produced between 2006 and 2014, not primarily focused on drink-driving or alcohol in pregnancy, and not alcohol industry funded. Systematic content analysis of all ads was performed; each ad was double-coded.

RESULTS

In total, 110 individual ads from 72 different alcohol harm reduction campaigns were identified, with the main source countries being Australia (40%) and the United Kingdom (26%). The dominant topic for 52% of ads was short-term harms, while 10% addressed long-term harms, 18% addressed underage drinking, 17% communicated a how-to-change message, and 3% advocated for policy change. The behavioural objective of most ads was to motivate audiences to reduce their alcohol consumption (38%) or to behave responsibly and/or not get drunk when drinking (33%). Only 10% of all ads mentioned low-risk drinking guidelines. Eighty-seven percent of ads used a dramatisation execution style and 74% had a negative emotional tone. Ninety percent of ads contained messages or content that appeared to target adults, and 36% specifically targeted young adults.

CONCLUSIONS

Some message attributes have been employed more frequently than others, suggesting several promising avenues for future audience or population-based research to compare the relative effectiveness of different characteristics of alcohol harm reduction ads. Given most alcohol-attributable harm is due to long-term disease, these findings suggest future campaigns may fill a potentially important gap if they were to focus on long-term harms. There is scope for such long-term harm campaigns to place greater emphasis on encouraging reduced personal consumption of alcohol, potentially through more frequent communication of low-risk drinking guidelines.