Assessing Constituent Levels in Smokeless Tobacco Products: A New Approach to Engaging and Educating the Public

Youth and adult understanding of public displays of information about harmful constituents in cigarette smoke

The U.S. FDA is required by law to publicly display a list of harmful and potentially harmful constituents (HPHCs) "by brand and by quantity in each brand and subbrand" in a format that is "understandable and not misleading to a lay person." An online experiment examined youth and adult understanding of which HPHCs are present in cigarette smoke, understanding of health effects of smoking cigarettes, and endorsement of misleading information after viewing HPHC information displayed in one of six formats. We recruited youth (N = 1324) and adults (N = 2904) from an online panel and randomized them to one of six formats of presenting HPHC information. Participants responded to survey items before and after exposure to an HPHC format. Understanding of HPHCs in cigarette smoke and understanding of health effects of cigarette smoking significantly increased pre- to post-exposure for all formats. Respondents (20.6% to 73.5%) endorsed misleading beliefs after exposure to information about HPHCs. Endorsement of the one misleading belief that was measured pre- and post-exposure significantly increased for viewers of four formats. All formats increased understanding of HPHCs in cigarette smoke and the health effects of smoking cigarettes, but some participants endorsed each misleading belief after exposure to HPHC information.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Design cues for tobacco communication: Heuristic interpretations and usability of online health information about harmful chemicals

OBJECTIVE

Many people have a poor understanding of the numerous chemicals in tobacco products that cause severe health harms. The US government must display a list of these harmful chemicals for the public. Online disclosures are one promising solution, but evidence is needed for effective design strategies to encourage interpretation and use of information as intended.

METHOD

To examine the impact of website designs for the activation of heuristics and usability perceptions, a national probability sample of US adolescents and adults (n = 1441) was randomized in a 3 (chemical format) × 2 (webpage layout) between-subjects online experiment. Chemicals were displayed as names only, with a visual risk indicator, or with numerical ranges. Layouts displayed health harms at the top of the webpage separate from chemicals or the chemicals grouped by associated health harms. Participants viewed a webpage and reported activated heuristics, usability (perceived ease of use and usefulness), and intentions to use the website.

RESULTS

Displaying risk indicators increased website usability by encouraging users to rely on colors to interpret the risk of the chemicals (all p < .01). Website designs that grouped chemicals with harms allowed users to link the chemicals to harms they cause and increased perceived usability and intentions to use the website (all p < .001).

CONCLUSION

Assessing heuristics gives insights for how US adolescents and adults interpret chemical information and the impact of design strategies on usability. Public disclosures of chemicals in tobacco products could be optimized with color-coded risk indicators and layouts placing chemicals near the harms they cause.

Polytobacco use and risk perceptions among young adults: The potential role of habituation to risk

INTRODUCTION

Polytobacco use and experimentation is common among young adults. Additional research is needed to determine how these patterns of use impact perceptions of tobacco-related harm and risk. The current study examined whether a relationship exists between an increased number of tobacco products used and decreases in perceptions of harmfulness and health risk.

METHOD

Participants (N = 792) completed a survey assessing current/lifetime tobacco use, perceived absolute harmfulness of tobacco/nicotine products and perceived health risk of smoking. For some analyses, participants were grouped by polytobacco use status.

RESULTS

Among participants who ever tried a tobacco product, a greater number of products tried was associated with lower perceptions of harm (all p < .05). For e-cigarettes and hookah, nonusers rated tobacco products as more harmful compared to single product, dual, and poly users (all p < .05). Number of products tried predicted perceived harmfulness above and beyond demographic characteristics and polytobacco use status across all products. Similarly, number of products tried predicted perceived health risk above and beyond demographic characteristics and polytobacco use status for both lung cancer and heart disease risk.

DISCUSSION

Trying a greater number of tobacco products is associated with lower perceived harmfulness of tobacco products. Prospective studies are needed to determine if experimentation with more tobacco products leads to reductions in perceived risk of tobacco use and subsequent sustained use of tobacco.

Mapping of Crowdsourcing in Health: Systematic Review

Background

Crowdsourcing involves obtaining ideas, needed services, or content by soliciting Web-based contributions from a crowd. The 4 types of crowdsourced tasks (problem solving, data processing, surveillance or monitoring, and surveying) can be applied in the 3 categories of health (promotion, research, and care).

Objective

This study aimed to map the different applications of crowdsourcing in health to assess the fields of health that are using crowdsourcing and the crowdsourced tasks used. We also describe the logistics of crowdsourcing and the characteristics of crowd workers.

Methods

MEDLINE, EMBASE, and ClinicalTrials.gov were searched for available reports from inception to March 30, 2016, with no restriction on language or publication status.

Results

We identified 202 relevant studies that used crowdsourcing, including 9 randomized controlled trials, of which only one had posted results at ClinicalTrials.gov. Crowdsourcing was used in health promotion (91/202, 45.0%), research (73/202, 36.1%), and care (38/202, 18.8%). The 4 most frequent areas of application were public health (67/202, 33.2%), psychiatry (32/202, 15.8%), surgery (22/202, 10.9%), and oncology (14/202, 6.9%). Half of the reports (99/202, 49.0%) referred to data processing, 34.6% (70/202) referred to surveying, 10.4% (21/202) referred to surveillance or monitoring, and 5.9% (12/202) referred to problem-solving. Labor market platforms (eg, Amazon Mechanical Turk) were used in most studies (190/202, 94%). The crowd workers’ characteristics were poorly reported, and crowdsourcing logistics were missing from two-thirds of the reports. When reported, the median size of the crowd was 424 (first and third quartiles: 167-802); crowd workers’ median age was 34 years (32-36). Crowd workers were mainly recruited nationally, particularly in the United States. For many studies (58.9%, 119/202), previous experience in crowdsourcing was required, and passing a qualification test or training was seldom needed (11.9% of studies; 24/202). For half of the studies, monetary incentives were mentioned, with mainly less than US $1 to perform the task. The time needed to perform the task was mostly less than 10 min (58.9% of studies; 119/202). Data quality validation was used in 54/202 studies (26.7%), mainly by attention check questions or by replicating the task with several crowd workers.

Conclusions

The use of crowdsourcing, which allows access to a large pool of participants as well as saving time in data collection, lowering costs, and speeding up innovations, is increasing in health promotion, research, and care. However, the description of crowdsourcing logistics and crowd workers’ characteristics is frequently missing in study reports and needs to be precisely reported to better interpret the study findings and replicate them.

The Effect of Tobacco Control Policies on US Smokeless Tobacco Use: A Structured Review

INTRODUCTION

Tobacco use has shifted increasingly from cigarettes to other products. While the focus has been mostly on cigarette-oriented policies, it is important to gauge the effects of policies targeting other products. We review and critique the literature on how policies affect smokeless tobacco (ST).

METHODS

We conducted a search of the literature on tobacco control policies as they relate to ST use, focusing on tobacco taxes, smoke-free air laws, media campaigns, advertising restrictions, health warnings, cessation treatment policies, and youth access policies. Findings from 78 total studies are summarized.

RESULTS

ST taxes, media campaigns, health warnings, and cessation treatment policies were found to be effective tools in reducing ST use. Evidence on the effects of current youth access policies is less strong. Studies have not yet been conducted on marketing or product content restrictions, but the literature indicates that product marketing, through advertising, packaging, flavorings, and extension of cigarette brands, plays an important role in ST use.

CONCLUSIONS

Although the evidence base is less established for ST policies than for cigarette policies, the existing literature indicates ST use responds to tobacco control policies. Policies should be structured in a way that aims to reduce all tobacco use while at the same time increasing the likelihood that continuing tobacco users use the least risky products.

IMPLICATIONS

Studies find that policies targeting smoking and policies targeting smokeless products affect smokeless use, but studies are needed to examine the effect of policies on the transitions between cigarette and smokeless use.

Online Information About Harmful Tobacco Constituents: A Content Analysis

Introduction

Tobacco products and smoke contain more than 7000 chemicals (ie, constituents). Research shows that consumers have poor understanding of tobacco constituents and find communication about them to be confusing. The current content analysis describes how information is communicated about tobacco constituents online in terms of source, target audience, and message.

Methods

A search was conducted in September 2015 using tobacco constituent and tobacco terms and identified 226 relevant Web sites for coding. Web sites were coded for type, target audience, reading level, constituent information, type of tobacco product, health effects, and emotional valence by two coders who independently coded half of the sample. There was a 20% overlap to assess interrater reliability, which was high (κ = .83, p < .001).

Results

The mean reading grade level of information online was 8.2 (SD = 2.8) with 81.7% of Web sites above the sixth grade reading level. Nearly all Web sites presented information in a qualitative narrative format (93%) and almost half (48.2%) presented information in a quantitative format. Nicotine (59.3%) and nitrosamines (28.8%) were the mostly frequently mentioned tobacco constituents. Cancer was the most frequently mentioned health effect (51.3%). Nearly a quarter (23%) of the Web sites did not explicitly state that tobacco constituents or tobacco products are associated with health effects.

Conclusion

Large gaps exist in online information about tobacco constituents including incomplete information about tobacco constituent-related health effects and limited information about tobacco products other than cigarettes and smokeless tobacco. This study highlights opportunities to improve the content and presentation of information related to tobacco constituents.

Implications

The US Food and Drug Administration (FDA) is required to publicly display a list of tobacco constituents in tobacco products and tobacco smoke by brand. However, little is known about tobacco constituent information available to the public. This is the first systematic content analysis of online information about tobacco constituents. The analysis reveals that although information about tobacco constituents is available online, large information gaps exist, including incomplete information about tobacco constituent-related health effects. This study highlights opportunities to improve the content and presentation of public information related to tobacco constituents.

How people think about the chemicals in cigarette smoke: a systematic review

Laws and treaties compel countries to inform the public about harmful chemicals (constituents) in cigarette smoke. To encourage relevant research by behavioral scientists, we provide a primer on cigarette smoke toxicology and summarize research on how the public thinks about cigarette smoke chemicals. We systematically searched PubMed in July 2016 and reviewed citations from included articles. Four central findings emerged across 46 articles that met inclusion criteria. First, people were familiar with very few chemicals in cigarette smoke. Second, people knew little about cigarette additives, assumed harmful chemicals are added during manufacturing, and perceived cigarettes without additives to be less harmful. Third, people wanted more information about constituents. Finally, well-presented chemical information increased knowledge and awareness and may change behavior. This research area is in urgent need of behavioral science. Future research should investigate whether educating the public about these chemicals increases risk perceptions and quitting.

A Proposed Collaboration Against Big Tobacco: Common Ground Between the Vaping and Public Health Community in the United States

An unfortunate conflict is underway between the public health community and the vaping community over e-cigarettes' harmfulness or lack thereof. This conflict is made worse by an information vacuum that is being filled by vocal members on both sides of the debate; a perceived lack of credibility of public health officials by those in the vaping community; the tobacco industry's recent involvement in e-cigarettes; and the constant evolution of different styles and types of e-cigarettes. This conflict is avoidable; common ground exists. If both groups rally around what is in their own and the public's best interest-the end of combustible tobacco--all will benefit significantly. If not, the result may be missed opportunities, misguided alliances, and--ultimately-poorer public health.

IMPLICATIONS

This study brings light to the contentious debate between the vaping and public health communities. It addresses how both sides are responsible for bringing misleading information to the public and vocal leaders on both sides are unknowingly intensifying and polarizing the debate-likely at the expense of public health. It also describes how this conflict is avoidable, and provides a starting point for potential positions of common ground against Big Tobacco.