Public understanding of cigarette smoke constituents: three US surveys

The Development and Testing of a Point-of-Sale E-Cigarette Health Communication Campaign

Adolescents and young adults continue to use e-cigarettes, and communication campaigns are needed to decrease use among these populations. We developed and tested a point-of-sale communication campaign focused on e-cigarette chemical exposure. We developed messages based on formative research and tested them (versus text-only messages) in a nationally-representative online survey among adolescents and young adults (16-25) (Phase 1). Based on survey findings, we selected a message focused on nicotine and brain development for the point-of-sale trial (Phase 2). We then conducted a cluster-randomized trial at six gas stations with convenience stores, randomly assigned to the intervention (messages displayed) or no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 participants (ages 16-25) per store, at baseline and a four-week follow-up. Phase 1 included 1,636 participants in the online study. Intervention messages were rated as more attention grabbing than plain text messages (p < .05), though were rated similarly on other outcomes. Exposure to intervention messages resulted in larger changes from pre- to posttest for beliefs about addiction and relative harms versus cigarettes (p < .05). Phase 2 included 586 participants in the point-of-sale study. Real-world campaign exposure was low (31.8%), and no differences were found between conditions. E-cigarette prevention messages focused on nicotine's impact on brain development show promise. However, garnering attention for communication campaigns in saturated point-of-sale environments, often dominated by tobacco advertising, is challenging. Future efforts should utilize additional communication channels to directly target adolescents and young adults.

Effects of Modified Risk Tobacco Product Claims on Consumer Responses

INTRODUCTION

US tobacco manufacturers can seek authorization from the US Food and Drug Administration (FDA) to market products using modified risk tobacco product (MRTP) claims. To inform regulatory decisions, we examined the impact of MRTP claim specificity and content, including whether the claims produced halo effects (ie, inferring health benefits beyond what is stated).

AIMS AND METHODS

Participants were 3161 US adult cigarette smokers. Using a two (general vs. specific) × 2 (risk vs. exposure) plus independent control design, we randomized participants to view one message from these conditions: general risk claim (eg, "smoking-related diseases"), general exposure claim (eg, "chemicals in smoke"), specific risk claim (eg, "lung cancer"), specific exposure claim (eg, "arsenic"), or control. Claims described the benefits of completely switching from cigarettes to the heated tobacco product IQOS.

RESULTS

MRTP claims of any sort elicited a higher willingness to try IQOS relative to control (d = 0.09, p = .043). Claims also elicited lower perceived risk of disease and exposure to harmful chemicals for completely switching from cigarettes to IQOS (d = -0.32 and -0.31) and partially switching (d = -0.25 and d = -0.26; all p < .05). Relative to specific MRTP claims, general MRTP claims led to lower perceived risk and exposure for complete switching (d = -0.13 and d = -0.16) and partial switching (d = -0.14 and d = -0.12; all p < .05). Risk and exposure MRTP claims had similar effects (all p > .05).

DISCUSSION

MRTP claims led to lower perceived risk and exposure, and higher willingness to try IQOS. General claims elicited larger effects than specific claims. MRTP claims also promoted unintended halo effects (eg, lower perceived risk of disease and chemical exposure for partial switching).

IMPLICATIONS

We found evidence that MRTP claims promoted health halo effects. In light of these findings, the FDA should require research on halo effects prior to authorization. Further, if an MRTP claim is authorized, FDA should require tobacco manufacturers to conduct post-market surveillance of how the claim affects consumer understanding, including partial switching perceived risk and exposure beliefs, as well as monitoring of dual-use behaviors.

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

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

Associations between smokers' knowledge of causes of smoking harm and related beliefs and behaviors: Findings from the International Tobacco Control (ITC) Four Country Smoking and Vaping Survey

BACKGROUND

Most smokers know that smoking is harmful to health, but less is known about their understanding of what causes the harms. The primary aim was to examine smokers' perceptions of the relative contributions to smoking-related morbidity from combustion products, nicotine, other substances present in unburned tobacco, and additives. A secondary aim was to evaluate the association of these perceptions with nicotine vaping product use intentions, and quitting motivation/intentions.

METHODS

Participants were current smokers and recent ex-smokers from Australia, Canada, England and the United States (N = 12,904, including 8511 daily smokers), surveyed in the 2018 International Tobacco Control Four Country Smoking and Vaping Survey. Respondents reported on how much they thought combustion products, nicotine, chemicals in the tobacco and additives in cigarettes contribute to smoking-related morbidity (none/very little; some but less than half; around half; more than half; all or nearly all of it; don't know).

RESULTS

Overall, 4% of participants provided estimates for all four component causes that fell within the ranges classified correct, with younger respondents and those from England most likely to be correct. Respondents who rated combustion as clearly more important than nicotine in causing harm (25%) were the least likely to be smoking daily and more likely to have quit and/or to be vaping. Among daily smokers, all four cause estimates were independently related to overall health worry and extent of wanting to quit, but the relative rating of combustion compared to nicotine did not add to prediction. Those who answered 'don't know' to the sources of harm questions and those suggesting very little harm were consistently least interested in quitting.

CONCLUSIONS

Most smokers' knowledge of specific causes of harm is currently inadequate and could impact their informed decision-making ability.

Longitudinal relationship between relative harm perceptions, beliefs about organic and additive-free tobacco, and cigarette brand switching among Natural American Spirit, Camel and Marlboro cigarette smokers

INTRODUCTION

While previous research has examined misperceptions related to Natural American Spirit (NAS), a premium cigarette brand using 'natural'-themed marketing, the longitudinal relationship between NAS-related harm beliefs and switching to NAS has not been established.

METHODS

Using data from the PATH study, we modelled the longitudinal relationship between (1) brand switching and subsequent belief that one's own brand might be less harmful than other brands (Waves 1-5); (2) belief that organic and/or additive-free tobacco products are less harmful and subsequent brand switching (Waves 3-5); and (3) belief that some types of cigarettes are less harmful and subsequent brand switching (Waves 3-5) for NAS and two leading comparator brands (Camel and Marlboro).

RESULTS

Among people who did not think their prior brand might be less harmful, switching to NAS or maintaining NAS preference increased the odds of believing one's own brand might be less harmful (aOR 19.4; 95% CI: 15.19, 24.8; aOR 6.1; 95% CI: 4.23, 8.67, respectively). Prior belief that organic and additive-free tobacco products were less harmful increased the odds of switching to (aOR 2.5; 95% CI: 1.68, 3.74) and decreased the odds of switching away (0.57; 955 CI: 0.36, 0.92) from NAS in the subsequent wave. Parallel analyses for Marlboro/Camel were largely null or in the opposite direction.

CONCLUSIONS

NAS use may maintain or shape new beliefs that the brand may be less harmful than other brands; holding pre-existing beliefs about the relative harm of some tobacco products may increase risk for NAS use.

Point-of-Sale Health Communication Campaigns for Cigarillos and Waterpipe Tobacco: Effects and Lessons Learned from Two Cluster Randomized Trials

Many adolescents and young adults hold erroneous beliefs that cigarillos and waterpipe tobacco (WT) are safer than cigarettes, contributing to use. Communication campaigns can correct misperceptions and increase risk beliefs. We tested point-of-sale (POS) communication campaigns focused on chemical exposure for cigarillos and WT. We conducted two cluster randomized trials at 20 gas stations with convenience stores (10 stores for cigarillos, 10 for WT) in North Carolina between June and November 2017. Within each trial, stores were randomly assigned to either the intervention (campaign messages displayed) or a no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 adolescents and young adults (ages 16-25) per store, at baseline and follow-up. There were 978 participants (mean age = 20.9 years) in the cigarillo trial, and 998 participants (mean age = 21.0 years) in the WT trial. Rates of campaign exposure were low (26% for cigarillos; 24.3% for WT). The cigarillo campaign increased knowledge that ammonia is in cigarillo smoke (p < .01). There were also significant increases in knowledge about ammonia and cyanide in cigarillo smoke and arsenic in WT smoke (p < .05) in the sub-sample who reported exposure to the campaign. No differences were found in outcome expectancies, product attitudes, worry about chemical exposure, or behavioral intentions in either campaign. Garnering attention for communication campaigns in saturated POS environments, often dominated by tobacco advertising, is challenging. Our study demonstrates the feasibility of anti-tobacco campaigns at the POS and points to several lessons learned for future POS campaigns.

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.

The Impact of Cannabis Packaging Characteristics on Perceptions and Intentions

INTRODUCTION

As cannabis increasingly becomes a consumer product in the U.S., its product packaging has become critically important to regulators. This study examined the influence of recreational cannabis packaging characteristics.

METHODS

Five online between-subjects experiments were conducted in April 2021, and data were analyzed in May 2021-July 2021. Experiments randomized participants to view different (1) types of cannabis, (2) visual displays of tetrahydrocannabinol content, (3) cannabis packages designed around brand personality research, (4) health warnings, and (5) health claims. Outcomes included cognitive, affective, and behavioral responses.

RESULTS

A total of 841 adults from the U.S. (49% male, 50% young adults, 44% White, 17% Hispanic) were included in the study. Edible gummies were perceived as healthier (β=0.32, 95% CI=0.03, 0.62), less grown up (β= -0.58, 95% CI= -0.86, -0.28), and more socially acceptable to consume (β=0.30, 95% CI=0.01, 0.59) than cannabis concentrate in a medical dropper. Participants also had more interest in trying edible gummies (β=1.33, 95% CI=1.04, 1.62) and trying a free sample (β=1.30, 95% CI=1.01, 1.60) than trying cannabis concentrate. Cannabis packages with a helps-you-relax health claim elicited more happy (β=0.34, 95% CI=0.04, 0.64) and good (β=0.37, 95% CI=0.07, 0.67) feelings than cannabis packages without this claim. Minimal effects were found for visual displays of tetrahydrocannabinol content and health warnings.

CONCLUSIONS

Edibles are a unique type of cannabis that should be given special consideration under state laws, and lawmakers should consider limiting and governing the use of both implicit and explicit health claims on recreational cannabis packages when implementing laws.

The effect of cigarette modified risk claims and brand on perceived risk, product appeal, and use intentions

OBJECTIVES

No studies have examined the brand context in which modified risk claims appear on tobacco products. This study examines how marketing products with modified risk claims affects risk perceptions, appeal, and intentions among own-brand, other brand, and novel brand cigarettes.

METHODS

This experiment employed a 3 (claim: risk modification [RM], exposure modification [EM], control) x 3 (brand: own, other, novel) between-subjects design. A convenience sample (N = 1,557, Mage = 40.28, SDage = 19.01, 71.3% female, 80.3% White) of current or former Marlboro, Camel, or Newport users was collected. Participants were assigned to view their own brand, another brand, or a novel brand, with or without a claim, and rated perceived risk after switching to this product, product appeal, and use intentions.

RESULTS

Participants in the RM or EM conditions had lower risk perceptions (versus control). Claim did not affect appeal. Adult established cigarette users in the EM (but not RM) condition had higher intentions (versus control). Participants rated their own and another brand as more appealing than the novel brand. Interactions between brand and claim were not significant.

CONCLUSIONS

We found modified risk claims decreased risk perceptions but did not impact appeal. Whereas participants showed preference for their own brand in terms of appeal and intentions, brand did not moderate the impact of claims.

Passive smoking and urinary oxidative biomarkers: A pilot study of healthy travelers from Los Angeles to Beijing

There is a great heterogeneity in smoking prevalence and tobacco control policy across different countries. However, it is unknown whether this heterogeneity could cause increased passive smoking and adverse health effects among international travelers. In this pilot study, we collected 190 urine samples from 26 Los Angeles residents before (LA-before), during (Beijing), and after (LA-after) a 10-week visit to Beijing to measure biomarkers of passive smoking (cotinine), exposure to polycyclic aromatic hydrocarbons (OH-PAHs), and oxidative stress (malondialdehyde, 8-isoprostane, and uric acid). The geometric mean concentrations of urinary cotinine were 0.14, 1.52, and 0.22 μg/g creatinine in LA-before, Beijing, and LA-after, respectively. Likewise, OH-PAH levels were significantly higher in Beijing as compared to LA-before or LA-after, in association with the urinary cotinine levels. One-fold increase in urinary cotinine levels was associated with 10.1% (95% CI: 5.53-14.8%), 8.75% (95% CI: 2.33-15.6%), and 25.4% (95%CI: 13.1-39.1%) increases in urinary levels of malondialdehyde, 8-isoprotane, and uric acid, respectively. OH-PAHs mediated 9.1-23.3% of the pro-oxidative effects associated with passive smoking. Taken together, our findings indicate that traveling to a city with higher smoking prevalence may increase passive smoking exposure, in association with pro-oxidative effects partially mediated by PAHs.

Beliefs and Characteristics Associated With Believing Nicotine Causes Cancer: A Descriptive Analysis to Inform Corrective Message Content and Priority Audiences

INTRODUCTION

Many cigarette smokers want to quit but have not. Switching to noncombustible products can reduce disease risk, but misperceptions that nicotine causes cancer might impact relative harm perceptions about noncombustible products and considering switching. Identifying which smokers are most likely to hold this misperception and associated beliefs can inform the content of and priority audiences for corrective messaging.

METHODS

Bivariable log binomial models were run on a sample of 9,013 adult established smokers from Wave 3 of the Population Assessment of Tobacco and Health. Post hoc testing identified groups and beliefs associated with significantly higher-than-average prevalence of the misperception.

RESULTS

About 61.2% of smokers believe nicotine causes cancer or don't know. Non-Hispanic Black (PR: 2.09) and Hispanic (PR: 1.73) smokers, as well as those making under $10,000 a year (PR: 1.36) had significantly higher-than-average prevalence of the misperception. Smokers who had recently used ENDS or smokeless tobacco had significantly lower-than-average prevalence of the misperception (PR: 0.70 and 0.63, respectively). Prevalence of nicotine misperceptions was significantly higher-than-average among those who recognized all ten smoking-caused diseases (PR: 1.34), believed additive-free cigarettes were more harmful than regular cigarettes (PR: 1.71), or did not report subjective norms supporting noncombustible use (PR: 1.05).

CONCLUSION

High perceived threat of tobacco may be overgeneralized to nicotine. High prevalence of the misperception among Non-Hispanic Black and low-income smokers is concerning, considering existing health disparities. Messaging should attempt to correct the misperception that nicotine causes cancer. Inferential reasoning after message exposure should assess accuracy of relative harm perceptions.

IMPLICATIONS

The current study supports the need for corrective messaging to address the misperception that nicotine causes cancer. Identifying that nicotine misperceptions are associated with higher harm perceptions about tobacco suggests that there may be unintended consequences of high perceived harm of tobacco that need to be addressed. As nicotine misperceptions are significantly more prevalent among those already at higher risk of tobacco caused diseases, care should be taken to ensure equity in message dissemination.

The influence of PM2.5 exposure on kidney diseases

The harm of air pollution to public health has become a research hotspot, especially atmospheric fine-particulate matter (PM_2.5). In recent years, epidemiological investigations have confirmed that PM_2.5 is closely related to chronic kidney disease and membranous nephropathy Basic research has demonstrated that PM_2.5 has an impact on the normal function of the kidneys through accumulation in the kidney, endothelial dysfunction, abnormal renin-angiotensin system, and immune complex deposition. Moreover, the mechanism of PM_2.5 damage to the kidney involves inflammation, oxidative stress, apoptosis, DNA damage, and autophagy. In this review, we summarized the latest developments in the effects of PM_2.5 on kidney disease in human and animal studies, so as to provide new ideas for the prevention and treatment of kidney disease.

Designing more effective cigar warnings: an experiment among adult cigar smokers

INTRODUCTION

Little systematic evidence exists about the effectiveness of cigar warnings. This study examined the perceived message effectiveness (PME) of warning statements about different health consequences caused by cigars. PME is a validated self-report scale of how effectively a health message discourages smoking.

METHODS

We conducted an online study from April-May 2020 with adults in the United States who used cigars in the past 30 days (n=777). Participants were randomly assigned to view and rate PME (3 items, range 1 to 5) for 7 out of 37 text warning statements about different health consequences from cigar use. Linear mixed effects models evaluated the most effective warning characteristics (e.g., type of health consequence), controlling for repeated measures and participant demographics.

RESULTS

Analyses showed that health consequences about the cardiovascular system (B=0.38), mouth (B=0.40), other digestive (B=0.45), respiratory system (B=0.36), and early death (B=0.36) were associated with higher PME scores than reproductive health consequences (all p-values <0.001). Similar results were found for these health consequences compared to addiction (all p-values p<0.001). We also observed that awareness of the health consequence was associated with higher PME scores (B=0.19, p<0.001) and length of the warning message (number of characters) was associated with lower PME scores (B=-0.007, p=0.03). No differences were observed between cancer and non-cancer health consequences (p=0.27) or health consequences that used plain language vs. medical jargon (p=0.94).

CONCLUSIONS

Our study provides new evidence about the perceived effectiveness of different cigar health warning statements and identifies features that may strengthen statements.

IMPLICATIONS

Our study with cigar smokers from across the United States provides much-needed evidence concerning the perceived effectiveness of different cigar health warning statements and features that may strengthen such statements. Mandated cigar warnings in the United States could be strengthened by including health consequences that were perceived as more effective in our study (e.g., early death), using health consequences that participants were aware of, and using short warning statements.

'It's all the other stuff!' How smokers understand (and misunderstand) chemicals in cigarettes and cigarette smoke

Many people understand chemicals as entities that do not occur naturally, and which are also invariably toxic. Tobacco control messages liberally use the term 'chemicals' to evoke these meanings and create concern among smokers. This may reinforce misunderstandings, potentially leading to smokers making harmful choices. To investigate smokers' understandings of chemicals, we conducted qualitative research using 18 individual interviews and three focus groups with Australian smokers and recently quit smokers. The research was guided by the 'mental models' framework and the recently developed Context, Executive, and Operational Systems theory. We discerned two clusters of mental models: the first cluster focused on combustion as the overarching cause of harm (and were largely consistent with the science) and the second cluster focused on additives as causes of harm. We found most participants displayed limited knowledge of the causes of harm from smoking and some held mutually incompatible beliefs. Most participants believed that cigarettes differ significantly in harmfulness according to whether or not they were believed to contain additives. Only a minority understood that the bulk of the toxicants to which smokers are exposed are combustion products. These findings are directly relevant to tobacco control but also have broader relevance to risk communications about toxic exposures.

The "organic" descriptor and its association with commercial cigarette health risk expectancies, subjective effects, and smoking topography: a pilot human laboratory study

INTRODUCTION

The purpose of this mixed method pilot study was to (1) examine whether the "organic" descriptor affects smokers' health risk expectancies, subjective ratings of smoking, and topography, and (2) describe how smokers interpret the "organic" descriptor and relate it to their subjective smoking experience.

METHODS

Twenty-two daily smokers (45.5% men, 81.8% non-Hispanic White, M (SD) age = 47.3 [12.7], M (SD) cigarettes/day = 14.5 [5.1]) completed a within-person laboratory study. Following a baseline session, smokers attended 2 experimental sessions where they smoked a study-provided cigarette (identical across conditions) paired with either an "organic" or conventional (e.g., no "organic") descriptor condition and completed subjective and behavioral measures. Participants completed a semi-structured interview at the last visit.

RESULTS

Relative to the conventional cigarette, more participants rated the "organic" cigarette as healthier, having fewer chemicals, and having a more favorable burn rate (p's<0.05). There were no differences in total puff volume by condition (p=0.42). Stratifying by gender, men inhaled 225 ml (SE = 82.7) more in the conventional condition (p=0.02); women inhaled 408 ml (SE = 233.3) more in the organic condition (p=0.11). A common understanding of "organic" was that the product was "…less processed... like less chemicals and it's more natural." Some believed that "organic" cigarettes contained fewer chemicals, which in turn produced a "much cleaner and healthier smoking cigarette" and that they could "taste the difference."

CONCLUSIONS

Findings support that smokers associate the "organic" descriptor with health and reduced harm. This descriptor may differentially impact puffing behavior by gender.

IMPLICATIONS

This study provides qualitative and quantitative data regarding how the "organic" descriptor influences adult daily smokers' perceptions and use of cigarettes. After smoking two identical cigarettes described as "organic" and conventional (e.g., no "organic"), smokers expressed more problematic health expectancies about the "organic" cigarette condition, providing further empirical support that the "organic" descriptor is associated with expectancies of reduced harm. The source of reduced harm was understood to be fewer chemicals in the organic cigarette. Though preliminary, findings suggest that "organic" may differentially affect puffing behavior by gender.

Awareness of and reactions to the health harms of sugary drinks: An online study of U.S. parents

Evidence about the health problems associated with sugary drink consumption is well-established. However, little is known about which sugary drink health harms are most effective at changing consumers' behavior. We aimed to identify which harms people were aware of and most discouraged them from wanting to buy sugary drinks. Participants were a national convenience sample of diverse parents (n = 1,058), oversampled for Latino parents (48%). Participants rated a list of sugary drink-related health harms occurring in children (7 harms) and in adults (15 harms). Outcomes were awareness of each harm and how much each harm discouraged parents from wanting to purchase sugary drinks. Most participants were aware that sugary drinks contribute to tooth decay in children (75%) and weight gain in both children (73%) and adults (69%). Few participants were aware that sugary drinks contribute to adult infertility (16%), arthritis (18%), and gout (18%). All health harms were rated highly in terms of discouraging parents from wanting to buy sugary drinks (range: 3.59-4.11 on a 1-5 scale), with obesity, pre-diabetes, and tooth decay eliciting the highest discouragement ratings. Harm-induced discouragement was higher for participants who were aware of more health harms (B = 0.05, p < 0.0001), identified as female (B = 0.15 compared to male, p = 0.02), or had an annual household income of $50,000 or more (B = 0.16 compared to less than $50,000, p = 0.03). These findings suggest health messages focused on a variety of health harms could raise awareness and discourage sugary drink purchases.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03339206.

Metabolic reprogramming: A driver of cigarette smoke-induced inflammatory lung diseases

Cigarette smoking is a well-known risk factor for pulmonary diseases, including chronic obstructive pulmonary disease (COPD), asthma and pulmonary fibrosis. Despite major progress in dissecting the mechanisms associated with disease development and progression, findings only represent one aspect of multifaceted disease. A crucial consequence of this approach is that many therapeutic treatments often fail to improve or reverse the disease state as other conditions and variables are insufficiently considered. To expand our understanding of pulmonary diseases, omics approaches, particularly metabolomics, has been emerging in the field. This strategy has been applied to identify putative biomarkers and novel mechanistic insights. In this review, we discuss metabolic profiles of patients with COPD, asthma, and idiopathic pulmonary fibrosis (IPF) with a focus on the direct effects of cigarette smoking in altering metabolic regulation. We next present cell- and animal-based experiments and point out the therapeutic potential of targeting metabolic reprogramming in inflammatory lung diseases. In addition, the obstacles in translating these findings into clinical practice, including potential adverse effects and limited pharmacological efficacy, are also addressed.

Reactions to messages about smoking, vaping and COVID-19: two national experiments

Introduction

The pace and scale of the COVID-19 pandemic, coupled with ongoing efforts by health agencies to communicate harms, have created a pressing need for data to inform messaging about smoking, vaping, and COVID-19. We examined reactions to COVID-19 and traditional health harms messages discouraging smoking and vaping.

Methods

Participants were a national convenience sample of 810 US adults recruited online in May 2020. All participated in a smoking message experiment and a vaping message experiment, presented in a random order. In each experiment, participants viewed one message formatted as a Twitter post. The experiments adopted a 3 (traditional health harms of smoking or vaping: three harms, one harm, absent) × 2 (COVID-19 harms: one harm, absent) between-subjects design. Outcomes included perceived message effectiveness (primary) and constructs from the Tobacco Warnings Model (secondary: attention, negative affect, cognitive elaboration, social interactions).

Results

Smoking messages with traditional or COVID-19 harms elicited higher perceived effectiveness for discouraging smoking than control messages without these harms (all p <0.001). However, including both traditional and COVID-19 harms in smoking messages had no benefit beyond including either alone. Smoking messages affected Tobacco Warnings Model constructs and did not elicit more reactance than control messages. Smoking messages also elicited higher perceived effectiveness for discouraging vaping. Including traditional harms in messages about vaping elicited higher perceived effectiveness for discouraging vaping (p <0.05), but including COVID-19 harms did not.

Conclusions

Messages linking smoking with COVID-19 may hold promise for discouraging smoking and may have the added benefit of also discouraging vaping.

Public Understanding of Cigarette Smoke Chemicals: Longitudinal Study of US Adults and Adolescents

INTRODUCTION

The US Food and Drug Administration has increased communication efforts that aim to raise public awareness of the harmful constituents (ie, chemicals) in cigarette smoke. We sought to investigate whether the public's awareness of these chemicals has increased in light of such efforts.

METHODS

Participants were national probability samples of 11 322 US adults and adolescents recruited in 2014-2015 (wave 1) and 2016-2017 (wave 2). Cross-sectional telephone surveys assessed awareness of 24 cigarette smoke chemicals at both timepoints.

RESULTS

The proportion of US adults aware of cigarette smoke chemicals did not differ between waves 1 and 2 (25% and 26%, p = .19). In contrast, awareness of chemicals among adolescents fell from 28% to 22% (p < .001), mostly due to lower awareness of carbon monoxide, arsenic, benzene, and four other chemicals. Belief that most of the harmful chemicals in cigarette smoke come from burning the cigarette also fell from waves 1 to 2 (adults: 31% vs. 26%; adolescents: 47% vs. 41%, both ps < .05). Participants were more likely to be aware of cigarette smoke chemicals if they had been exposed to anti-smoking campaign advertisements (p < .05) or had previously sought chemical information (p < .05). Cigarette smoke chemical awareness did not differ between smokers and nonsmokers.

CONCLUSION

Awareness of cigarette smoke chemicals remains low and unchanged among adults and decreased somewhat among adolescents. The association of chemical awareness with information exposure via campaigns and information seeking behavior is promising. More concerted communication efforts may be needed to increase public awareness of cigarette smoke chemicals, which could potentially discourage smoking.

IMPLICATIONS

Awareness of the toxic chemicals in cigarette smoke may contribute to quitting. The US Food and Drug Administration is making efforts to increase public awareness of these chemicals. Two national surveys (2014-2017) found that chemical awareness was low among adults and adolescents. Although awareness did not change among adults, awareness among adolescents dropped over time. In addition, exposure to anti-smoking campaigns and chemical information seeking behavior were associated with higher awareness of chemicals in cigarette smoke. Campaigns and other efforts may be needed to increase awareness of cigarette smoke chemicals.

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.

Similarities and Differences in Tobacco Control Research Findings From Convenience and Probability Samples

BACKGROUND

Online convenience samples are a quick and low-cost way to study health behavior, but the comparability to findings from probability samples is not yet well understood.

PURPOSE

We sought to compare convenience and probability samples' findings for experiments, correlates, and prevalence in the context of tobacco control research.

METHODS

Participants were a probability sample of 5,014 U.S. adults recruited by phone from September 2014 through May 2015 (cost ~U.S.$620,000) and an online convenience sample of 4,137 U.S. adults recruited through Amazon Mechanical Turk (MTurk) in December 2014 (cost ~U.S.$17,000). Participants completed a survey with experiments, measures of tobacco product use and demographic characteristics.

RESULTS

MTurk convenience and probability samples showed the same pattern of statistical significance and direction in almost all experiments (21 of 24 analyses did not differ) and observational studies (19 of 25 associations did not differ). Demographic characteristics of the samples differed substantially (1 of 17 estimates did not differ), with the convenience sample being younger, having more years of education, and including more Whites and Asians. Tobacco product use also differed substantially (1 of 22 prevalence estimates did not differ), with the convenience sample reporting more cigarette and e-cigarette use (median error 19%).

CONCLUSIONS

Using MTurk convenience samples can yield generalizable findings for experiments and observational studies. Prevalence estimates from MTurk convenience samples are likely to be over- or underestimates.

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

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

IMPLICATIONS

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

The Influence of Various Smoking Categories on The Risk of Gestational Hypertension and Pre-Eclampsia

The relationship between smoking and the risk of pregnancy-induced hypertension (PIH) is not clearly established. Therefore, we conducted an analysis of cigarette smoking in a Polish cohort of women, recruited in the first trimester of a single pregnancy in 2015–2016. We evaluated the women who subsequently developed PIH (n = 137) (gestational hypertension—GH (n = 113) and pre-eclampsia—PE (n = 24)), and the women who remained normotensive (n = 775). The diseases odds ratios (and 95% CI—confidence intervals) were calculated in a multivariate logistic regression. In the PIH cases (vs. normotensive women) we found more smokers (25.6% vs. 17.2%, p = 0.020) including smokers in the first trimester (14.6% vs. 4.8%, p < 0.001). The average number of cigarettes smoked daily per smokers in the first trimester was 11.2 (range 2–30), and the average number of years of smoking was 11.6 (range 2–25). The number of years of smoking was a stronger risk factor for GH and PE than the number of cigarettes/day. Compared to the women who have never smoked, smoking ever before pregnancy was associated with a higher GH risk (AOR = 1.68; p = 0.043), and with no effect on PE risk (OR = 0.97; p = 0.950). Smokers in the first trimester had a higher odds ratio of GH (AOR = 4.75; p < 0.001) and PE (OR = 2.60; p = 0.136). Quitting smoking before pregnancy (ex-smokers) was associated with a lower odds ratio of GH (AOR = 0.83; p = 0.596) and PE (OR = 0.33; p = 0.288). However, quitting smoking during pregnancy was associated with a higher risk of GH (AOR = 11.63; p < 0.0001) and PE (OR = 3.57; p = 0.238). After dissection of the cohort into pre-pregnancy body–mass index (BMI) categories, smoking in the first trimester was associated with the higher hypertension risk in underweight women (OR = 22.00, p = 0.024). Conclusions: The factors that increased the risk of GH and PE were smoking in the first trimester and (paradoxically and more strongly) smoking cessation during pregnancy. Our results suggest that women of childbearing potential should be encouraged to quit smoking before pregnancy.

One-item susceptibility measure predicts waterpipe and little cigar/cigarillo uptake in a national sample of adolescents and young adults in the United States

INTRODUCTION

Adolescents and young adults in the United States (US) are increasingly using non-cigarette tobacco products such as waterpipe (WP) and little cigars/cigarillos (LCC). One way to predict which non-user adolescents and young adults are most likely to use these products is through measuring their susceptibility or openness to using the products.

METHODS

We conducted a national phone survey (baseline) and an internet survey (follow-up) of adolescents and young adults (ages 13–25 years), who, at baseline, had never used WP (N=1002) or LCC (N=990). At baseline, we measured susceptibility using a single item, asking participants whether they would try WP or LCC if their best friend offered it to them, and subsequently measured uptake at follow-up. We conducted multivariate regression analyses to determine whether product-specific susceptibility was a significant predictor of uptake at follow-up.

RESULTS

Participants who were susceptible and participants who had ever used another tobacco product had higher odds of using WP (AOR=3.5, AOR=4.2) and LCC (AOR=3.2, AOR=5.3) at follow-up than those who were not susceptible to those products, and had not ever used tobacco products respectively, controlling for sociodemographic factors. The one-item measure had adequate sensitivity (WP=51.4%, LCC=40.2%) and specificity (WP=84.9%, LCC=87.9%).

CONCLUSIONS

Our national study of US adolescents and young adults shows that a one-item susceptibility measure at baseline was a significant predictor of WP and LCC uptake at follow-up, even after controlling for other predictors. Future research should assess the predictive validity of the one-item compared to the multi-item scale.

Cigarette Constituent Health Communications for Smokers: Impact of Chemical, Imagery, and Source

INTRODUCTION

Communication campaigns are incorporating tobacco constituent messaging to reach smokers, yet there is a dearth of research on how such messages should be constructed or will be received by smokers.

METHODS

In a 2 × 2 × 2 experiment, we manipulated three cigarette constituent message components: (1) the toxic constituent of tobacco (arsenic vs. lead) with a corresponding health effect, (2) the presence or absence of an evocative image, and (3) the source of the message (FDA vs. no source). We recruited smokers (N = 1669, 55.4% women) via an online platform and randomized them to one of the eight message conditions. Participants viewed the message and rated its believability and perceived effectiveness, the credibility of the message source, and action expectancies (ie, likelihood of seeking additional information and help with quitting as a result of seeing the message).

RESULTS

We found significant main effects of image, constituent, and source on outcomes. The use of arsenic as the constituent, the presence of an evocative image, and the FDA as the source increased the believability, source credibility, and perceived effectiveness of the tobacco constituent health message.

CONCLUSIONS

Multiple elements of a constituent message, including type of constituent, imagery, and message source, impact their reception among smokers. Specifically, communication campaigns targeting smokers that utilize arsenic as the tobacco constituent, visual imagery, and the FDA logo may be particularly effective in changing key outcomes that are associated with subsequent attitude and behavioral changes.

IMPLICATIONS

This article describes how components of communication campaigns about cigarette constituents are perceived. Multiple elements of a tobacco constituent message, including type of constituent, image, and message source may influence the reception of messages among current smokers. Communication campaigns targeting smokers that utilize arsenic as the tobacco constituent, visual imagery, and the FDA logo may be particularly effective in changing key outcomes among smokers. The effects of such campaigns should be examined, as well as the mechanisms through which such campaigns affect change.

Effects of a Nicotine Fact Sheet on Perceived Risk of Nicotine and E-Cigarettes and Intentions to Seek Information About and Use E-Cigarettes

We examined how a nicotine fact sheet influenced smokers’ beliefs about nicotine and electronic cigarettes (e-cigarettes), a potentially less harmful alternative to conventional cigarettes. In an exploratory online experiment, 756 US adult current and recent former smokers (quit in the past 2 years) were randomized to view a nicotine fact sheet or control messages (bottled water ads). Effects of the nicotine fact sheet on perceived nicotine addictiveness, nicotine risk, comparative risk of e-cigarettes, and dual use intentions were analyzed using log-Poisson regression with robust error. Linear regression analyzed effects on perceived absolute risk and switching and information seeking intentions about e-cigarettes. Compared to control, the nicotine fact sheet doubled the probability of disagreeing that nicotine is the main cause of smoking-related disease (26.2% vs. 12.7%, RR = 2.06, 95% CI = 1.51, 2.82, p < 0.001). However, nearly three quarters of participants viewing the nicotine fact sheet still thought that nicotine is the main cause of smoking-related disease. The nicotine fact sheet increased smokers’ intentions to seek information about e-cigarettes (b = 0.45, 95% CI = 0.15, 0.74, p = 0.003). We did not find evidence suggesting unintended consequences of the nicotine fact sheet on smokers’ e-cigarettes risk perceptions or use intentions (e.g., increased dual use intentions or reduced absolute e-cigarette risk perception).

Knowledge and Awareness of Added Sugar in Cigarettes

INTRODUCTION

Sugars naturally occur in tobacco leaf but are also commonly added to cigarettes by tobacco companies. Added sugar increases levels of toxic chemicals in cigarette smoke. Little is known about smokers' knowledge of added sugar in cigarettes and awareness of its effects.

METHODS

Adult cigarette smokers were recruited through Amazon Mechanical Turk to participate in an online experiment on electronic cigarette advertising. After completing the experiment, participants (N = 4351) answered two items assessing knowledge and awareness of added sugar in cigarettes. Participants had the option of providing open-ended comments about the overall study, and two reviewers read and independently coded comments pertaining to the sugar items.

RESULTS

Only 5.5% of participants responded "yes" to the question: "Is sugar added to cigarettes?", and only 3.8% of participants indicated being aware that added sugar increases toxins in cigarette smoke. Forty-eight participants mentioned the sugar items when asked to comment about the overall questionnaire. Fifty-two percent of these comments expressed an interest in obtaining more information about added sugar, and 23% described the sugar items as interesting or informative. Three participants commented that learning about added sugar motivated them to quit or cut down on smoking.

CONCLUSIONS

Among a large sample of smokers, few reported knowledge of added sugar in cigarettes and awareness of its effects. Further, several smokers expressed an interest in learning more about added sugar. Messages about added sugar in cigarettes may be a promising new angle for campaigns to discourage smoking.

IMPLICATIONS

Few American smokers are aware that sugar is added to cigarettes, and some participants expressed a desire to learn more about this additive. Given such low awareness, the interest among smokers, and increased popular concerns about added sugar in foods and beverages, messaging about added sugar in cigarettes should be developed and tested for inclusion in public health media campaigns.

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.

Understandings of the component causes of harm from cigarette smoking in Australia

INTRODUCTION AND AIMS

To investigate relationships between smoking-related behaviours and knowledge of the disease risks of smoking and the causes of smoking harms, using a four-way division of 'component causes': nicotine, other substances found in unburned tobacco, combustion products of tobacco and additives.

DESIGN AND METHODS

The data were collected using an on-line survey in Australia with 1047 participants in three groups; young non-smokers (18 to 25), young smokers (18 to 25) and older smokers (26 and above).

RESULTS

Most participants agreed that cancer and heart disease are major risks of smoking but only a quarter accurately quantified the mortality risk of lifetime daily smoking. Very few (two of 1047) correctly estimated the relative contributions of all four component causes. Post-hoc analyses reinterpreting responses as expressions of relative concern about combustion products and nicotine showed that 29% of participants rated combustion products above nicotine. We delineated six relative concern segments, most of which had distinctive patterns of beliefs and actions. However, higher levels of concern about combustion products were only weakly positively associated with harm reducing beliefs and actions.

DISCUSSION AND CONCLUSIONS

Most smokers do not appear to understand the risks of smoking and their causes well enough to be able to think systematically about the courses of action open to them to reduce their health risk. To facilitate informed decision-making, tobacco control communicators may need to better balance the dual aims of creating fear/negative affect about smoking and imparting knowledge about the health harms and their mechanisms.

Periodontal Disease Status among Adults from South Africa-Prevalence and Effect of Smoking

Periodontal diseases are among the six most prevalent non-communicable diseases (NCDs) worldwide, constituting a burden for oral and general health. There is a shortage of epidemiological data on periodontal diseases in Africa. The aim of the present cross-sectional study was to present the periodontal status and cotinine levels of a South African population of adults. This study included individuals living in the Belville South area. Bleeding on probing (BOP) and pocket depth were recorded for each tooth, and clinical attachment loss (CAL) was recorded as the highest score per sextant. Cotinine levels were measured in ng/mL. A total of 951 individuals were included. More than one third of all subjects had BOP. Regarding pocket depth, over 50% of the subjects had shallow pockets (4-5 mm), and almost 6% had deep pockets. CAL ≥ 4 mm was present in 40.1% of the subjects. Males presented worse periodontal conditions than females. In total, 52.7% of the participants had serum cotinine levels of ≥15 ng/mL. Cotinine levels had no effect on periodontal variables. Periodontal diseases were highly prevalent, and periodontal conditions were worse in males. Preventive and restorative public health programs are required to improve oral health in this population.

Communicating about chemicals in cigarette smoke: impact on knowledge and misunderstanding

BACKGROUND

The USA must publicly share information about harmful and potentially harmful constituents (chemicals) in tobacco products. We sought to understand whether webpages with chemical information are "understandable and not misleading to a lay person."

METHODS

Participants were a national probability sample of US adults and adolescents (n=1441, 18% smokers). In an online experiment, we randomly assigned participants to view one of the developed webpages (chemical names only, names with quantity ranges, names with visual risk indicators) or no webpage in phase one (between subjects). Participants completed a survey assessing knowledge, misunderstanding, perceived likelihood, perceived severity of health effects from smoking and quit intentions (smokers only). In phase two (within subjects), participants viewed all three webpage formats and reported webpage perceptions (clarity, usability, usefulness) and perceived impact (affect, elaboration, perceived effectiveness).

RESULTS

In phase one, viewing any webpage led to more knowledge of chemicals (48%-54% vs 28% no webpage, ps<0.001) and health harms (77% vs 67% no webpage, ps<0.001). When exposed to any webpage, 5%-23% endorsed misunderstandings that some cigarettes are safer than others. Webpage format did not affect knowledge or reduce misunderstandings. Viewing any webpage led to higher perceived likelihood of experiencing health effects from smoking (p<0.001) and, among smokers, greater intentions to quit smoking (p=0.04). In phase two, where participants viewed all formats, a visual risk indicator led to the highest perceived impact.

CONCLUSIONS

Knowledge of chemicals and health effects can increase after viewing a website. Yet, websites may not correct the misunderstanding that some cigarettes are safer.

UNC Perceived Message Effectiveness: Validation of a Brief Scale

BACKGROUND

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

PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Interest in "organic," "natural," and "additive-free" cigarettes after hearing about toxic chemicals in cigarette smoke

INTRODUCTION

The US Family Smoking Prevention and Tobacco Control Act requires the government to disseminate information about the toxic chemicals in cigarette smoke. We sought to understand how the descriptors "organic," "natural," or "additive-free" affect smokers' interest in cigarettes in the context of information about chemicals in cigarette smoke.

METHODS

Participants were a national probability sample of 1,101 US adult (ages ≥18) smokers recruited in 2014-2015. A between-subjects experiment randomized participants in a telephone survey to 1 of 4 cigarette descriptors: "organic," "natural," "additive-free," or "ultra-light" (control). The outcome was expected interest in cigarettes with the experimentally assigned descriptor, after learning that 2 chemicals (hydrogen cyanide and lead) are in cigarette smoke. Experimental data analysis was conducted in 2016-2017.

RESULTS

Smokers indicated greater expected interest in "organic," "natural," and "additive-free" cigarettes than "ultra-light" cigarettes (all p <.001) after learning that hydrogen cyanide and lead were in cigarette smoke. Smokers who intended to quit in the next 6 months expressed greater expected interest in the 4 types of cigarettes ("organic," "natural," "additive-free," and "ultra-light") compared to smokers not intending to quit (p <.001).

CONCLUSIONS

Smokers, especially those intending to quit, may be more inclined towards cigarettes described as "organic," "natural," and "additive-free" in the context of chemical information. An accumulating body of evidence shows that the US should fully restrict use of "organic" and "natural" descriptors for tobacco products as it has done for "additive-free" and "light" descriptors.

Website Designs for Communicating About Chemicals in Cigarette Smoke

The Family Smoking Prevention and Tobacco Control Act requires the US government to inform the public about the quantities of toxic chemicals in cigarette smoke. A website can accomplish this task efficiently, but the site's user interface must be usable to benefit the general public. We conducted online experiments with national convenience samples of 1,451 US adult smokers and nonsmokers to examine the impact of four interface display elements: the chemicals, their associated health effects, quantity information, and a visual risk indicator. Outcomes were perceptions of user experience (perceived clarity and usability), motivation (willingness to use), and potential impact (elaboration about the harms of smoking). We found displaying health effects as text with icons, providing quantity information for chemicals (e.g., ranges), and showing a visual risk indicator all improved the user experience of a webpage about chemicals in cigarette smoke (all p < .05). Displaying a combination of familiar and unfamiliar chemicals, providing quantity information for chemicals, and showing a visual risk indicator all improved motivation to use the webpage (all p < .05). Displaying health effects or quantity information increased the potential impact of the webpage (all p < .05). Overall, interface designs displaying health effects of chemicals in cigarette smoke as text with icons and with a visual risk indicator had the greatest impact on the user experience, motivation, and potential impact of the website. Our findings provide guidance for accessible website designs that can inform consumers about the toxic chemicals in cigarette smoke.

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

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

Association of exercise with smoking-related symptomatology, smoking behavior and impulsivity in men and women

INTRODUCTION

Despite extensive efforts to develop effective smoking cessation interventions, 70-85% of American cigarette smokers who quit relapse within one year. Exercise has shown promise as an intervention; however, many results have been equivocal. This study explored how exercise is associated with smoking-related symptomatology, smoking behavior and impulsivity in male and female smokers.

METHODS

Participants were recruited throughout the United States using the on-line crowdsourcing platform, Amazon's Mechanical Turk. They completed a survey with self-report measures assessing exercise, smoking-related symptomatology, smoking behavior and impulsivity. Differences between men and women were tested using t- and chi-square tests. Regression analyses tested for associations between exercise and smoking-related symptomatology, smoking behavior and impulsivity.

RESULTS

Participants (N = 604) were, on average, 32 (SD = 6.2) years old, mostly Caucasian, with at least some college education and approximately half were women. Women exercised slightly less than men and had more negative affect, craving, physical symptoms and withdrawal. Women smoked more cigarettes per day, had greater nicotine dependency and more years of smoking. Positive affect was positively associated with exercise for both men and women; however, this association was significantly stronger in women. Negative affect and withdrawal were inversely associated with exercise for women only. Impulsivity was inversely associated with exercise for both men and women.

CONCLUSION

Exercise was significantly associated with several smoking-related symptomatology, smoking behavior and impulsivity variables for both men and women, suggesting that exercise may be a useful intervention for smoking cessation. Future prospective research should determine how exercise directly impacts smoking cessation.

Effective Message Elements for Disclosures About Chemicals in Cigarette Smoke

Introduction

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

Methods

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

Results

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

Conclusions

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

Implications

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

Increasing Effectiveness of Messages about Chemicals in Cigarette Smoke

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Role of Knowledge and Risk Beliefs in Adolescent E-Cigarette Use: A Pilot Study

The use of e-cigarettes and other vaping devices among adolescents is an urgent public health problem due to the concern about adolescent exposure to nicotine. This study examined: (1) adolescents’ knowledge and beliefs about e-cigarette risks; and (2) whether knowledge and risk beliefs were associated with e-cigarette use. N = 69 adolescents completed a cross-sectional survey about e-cigarette knowledge, attitudes (i.e., risk beliefs), and behavior (KAB). Nearly half (47%) of the sample reported ever using e-cigarettes. The majority of adolescents knew about many of the risks of e-cigarettes, with no differences between never- and ever-users. However, risk beliefs, such as worrying about health risks of using e-cigarettes, varied across groups. Compared to never-users, e-cigarette ever-users were significantly less likely to worry about e-cigarette health risks, less likely to think that e-cigarettes would cause them negative health consequences, and less likely to believe that e-cigarette use would lead to addiction. In a multivariable logistic regression, prior combustible cigarette use, mother’s education, and addiction risk beliefs about e-cigarettes emerged as significant predictors of adolescents’ e-cigarette use. This study reveals that while knowledge is not associated with adolescent e-cigarette use, risk beliefs do predict use.

A bibliometric analysis of clinical study literature of traditional Chinese medicine therapies for smoking cessation

INTRODUCTION

Traditional Chinese medicine (TCM) is commonly used for smoking cessation in China. The aim of this study is to perform a comprehensive literature search to identify clinical studies on TCM therapies for smoking cessation.

METHODS

Publications of randomized controlled trials, controlled clinical studies, cohort studies, case-control studies, case series and case reports, reviews and cross-sectional studies on smoking cessation using TCM therapies were retrieved from seven databases from their inception to February 2017. The following data were extracted and analyzed: study type, year of publication, language, country or region, journals, participants, intervention and comparison, and outcome.

RESULTS

In total, 260 publications on TCM therapies for smoking cessation were identified from 1980 to 2016, including 52 randomized clinical trials, 7 controlled clinical studies, 1 cohort study, 110 case series, 18 case reports, 50 narrative reviews, 17 systematic reviews, and 5 cross-sectional studies. Of these, 68.5% (178) were published in Chinese and the remaining published in English. Mainland China (n=129, 49.6%) was the leading country in this field, followed by USA (n=27, 10.4%) and UK (n=25, 9.6%). A total of 36 645 participants from 40 countries with age ranging from 12 to 86 years were involved in 188 clinical studies (excluding reviews and cross-sectional studies). The most commonly reported therapies were auricular acupressure (25, 13.3%), body acupuncture (14, 7.4%), and body acupuncture plus auricular acupressure (14, 7.4%). Composite outcomes were most frequently reported (110, 58.5%).

CONCLUSIONS

A substantial number of clinical studies have been conducted and published on TCM therapy for smoking cessation, mainly focusing on acupuncture stimulation techniques. The findings suggest that future research should pay more attention to acupuncture for smoking cessation.

Smokers' unprompted comments on cigarette additives during conversations about the genetic basis for nicotine addiction: a focus group study

BACKGROUND

Research designed to elicit smokers' cognitive and affective reactions to information about chemicals that tobacco companies add to cigarettes ("additives") found that knowledge is limited. However, little is known about smokers' unprompted thoughts and feelings about additives. Such information could be used to shape future communication efforts. We explored the content and possible functions of spontaneous statements about cigarette additives made by smokers during a study examining reactions to learning about the genetic link to nicotine addiction.

METHODS

Adult smokers (N = 84) were recruited from a medium-sized Midwestern city. Focus groups (N = 13) were conducted between April-September 2012. Data were analyzed by 2 coders using thematic analysis.

RESULTS

Comments about cigarette additives arose without prompting by the focus group moderator. Three main themes were identified: (1) discussing additives helped participants navigate the conceptual link between smoking and genetics, (2) additives were discussed as an alternative mechanism for addiction to cigarettes, and (3) additives provided an alternative mechanism by which cigarette smoking exacerbates physical harm. Notably, discussion of additives contained a pervasive tone of mistrust illustrated by words like "they" and "them," by statements of uncertainty such as "you don't know what they're putting into cigarettes," and by negative affective verbalizations such as "nasty" and "disgusting".

CONCLUSIONS

Participants had distinct beliefs about cigarette additives, each of which seemed to serve a purpose. Although mistrust may complicate communication about the health risks of tobacco use, health communication experts could use smokers' existing beliefs and feelings to better design more effective anti-smoking messages.

Effective Formats for Communicating Risks from Cigarette Smoke Chemicals

Objective

The US government requires the public display of information about toxic chemicals in cigarettes and smoke by brand in a way that is understandable and not misleading. We sought to identify risk communication formats that meet these goals.

Methods

We conducted 3 online experiments with US adult convenience samples (total N = 1866). Participants viewed a webpage displaying information about chemicals in the smoke of a cigarette brand. Experiment 1 varied the chemicals listed and format for their health effects. Experiments 2 and 3 varied the format of chemical quantities and presence/absence of a visual risk indicator. Outcomes were understandable (increasing knowledge) and not misleading (not reinforcing misperceptions).

Results

Information about chemicals and health effects increased knowledge of these topics by ~30% (p < .001) compared to no information. Quantity format and use of a risk indicator generally did not affect knowledge. The proportion of participants misled ranged from 0% to 92%, depending on measure. Findings indicated 52% would use a website to search for safer cigarettes. Risk communication formats did little to reduce being misled.

Conclusions

Some risk communication formats successfully increased knowledge of chemicals and health effects. However, the formats did little to reduce the proportion of people misled.

Brand switching and toxic chemicals in cigarette smoke: A national study

Introduction

US law requires disclosure of quantities of toxic chemicals (constituents) in cigarette smoke by brand and sub-brand. This information may drive smokers to switch to cigarettes with lower chemical quantities, under the misperception that doing so can reduce health risk. We sought to understand past brand-switching behavior and whether learning about specific chemicals in cigarette smoke increases susceptibility to brand switching.

Methods

Participants were US adult smokers surveyed by phone (n = 1,151, probability sample) and online (n = 1,561, convenience sample). Surveys assessed whether smokers had ever switched cigarette brands or styles to reduce health risk and about likelihood of switching if the smoker learned their brand had more of a specific chemical than other cigarettes. Chemicals presented were nicotine, carbon monoxide, lead, formaldehyde, arsenic, and ammonia.

Results

Past brand switching to reduce health risk was common among smokers (43% in phone survey, 28% in online survey). Smokers who were female, over 25, and current “light” cigarette users were more likely to have switched brands to reduce health risks (all p < .05). Overall, 61–92% of smokers were susceptible to brand switching based on information about particular chemicals. In both samples, lead, formaldehyde, arsenic, and ammonia led to more susceptibility to switch than nicotine (all p < .05).

Conclusions

Many US smokers have switched brands or styles to reduce health risks. The majority said they might or would definitely switch brands if they learned their cigarettes had more of a toxic chemical than other brands. Brand switching is a probable unintended consequence of communications that show differences in smoke chemicals between brands.