Assessing Smoking Cessation Messages with a Discrete Choice Experiment

Identifying attributes of effective cigar warnings: a choice-based conjoint experiment in an online survey of US adults who smoke cigars

OBJECTIVE

Little evidence exists on which cigar warning statement attributes may impact cigar warning effectiveness; research is needed to identify the most effective cigar warning topics and text. This study was designed to inform the development of improved cigar warnings.

DESIGN

We conducted a choice-based conjoint experiment. The experiment systematically manipulated cigar warning statement attributes, including cancer health effect (mention of colon cancer and/or oral cancer), non-cancer health effect (mention of heart disease and/or blood clots), causal language, warning marker word, verb use and tobacco type. Participants evaluated eight choice sets, each containing three cigar warnings with contrasting attributes, and chose the warnings that most and least encouraged them to quit smoking cigars. Using a Bayesian mixed logit model, we estimated the relative importance of each attribute and the attribute part-worth utility.

SETTING

An online survey of adults in the USA.

PARTICIPANTS

We enrolled 959 US adults who used little cigars, cigarillos, or large cigars in the past 30 days using an online survey from October to December 2020.

PRIMARY OUTCOME MEASURES

The primary outcomes for the experiment are relative attribute importance and attribute part-worth utility.

RESULTS

The most important attributes to participant selection of warnings were the non-cancer and the cancer health effects (29.3%; 95%CI 28.6% to 30.0% and 29.0%; 95% CI 28.4% to 29.6%, respectively), followed by causal language (16.3%; 95% CI 15.7% to 16.8%), marker word (10.3%; 95% CI 9.9% to 10.7%), verb use (8.8%; 95% CI 8.5% to 9.2%) and tobacco type (6.3%, 95% CI 5.9% to 6.6%).

CONCLUSIONS

Our findings indicate that health effects are the most important attributes when designing cigar warning statements, but other attributes, like causal terminology, also influence perceived warning effectiveness. Based on our findings, 'DANGER: Tobacco causes heart disease and blood clots' is an example of a highly effective warning statement for cigars.

Differential Responses to Cigarette Package Labeling Alternatives Among Adults Who Smoke: Results From a Randomized Trial

INTRODUCTION

Little experimental research has evaluated whether the effects of cigarette package inserts with efficacy messages and/or pictorial health warning labels (PHWLs) differ across key subgroups of adults who smoke.

AIMS AND METHODS

Adults who reported currently smoking (n = 367) were randomly assigned to one of four groups: Small text-only HWLs on pack sides (control); inserts with efficacy messages and small HWLs (inserts-only); PHWLs showing harms of smoking (PHWLs-only); both (inserts + PHWLs). Participants received a 14-day supply of cigarettes labeled to reflect their group. Every evening over 2 weeks, participants reported forgoing and stubbing out cigarettes before they finished smoking over the prior 24 hours, combined into a binary indicator of either behavior (eg, forgoing/stubbing). Separate mixed-effects logistic models were estimated to evaluate moderation of labeling group contrasts (ie, PHWLs vs not; inserts vs. not; inserts-only vs. inserts + PHWLs; PHWLs-only vs. inserts + PHWLs) by baseline covariates (self-efficacy to quit, intention to quit, education, health literacy, and time discounting), predicting day-level forgoing/stubbing.

RESULTS

Education moderated PHWL effects, with PHWLs predicting more forgoing/stubbing only among those with low education (OR = 4.68, p < .001). Time discounting moderated insert effects, with inserts promoting forgoing/stubbing only among those with low time discounting (ie, lower impulsivity; OR = 4.35, p < .001).

CONCLUSIONS

Inserts with efficacy messages appear effective mostly among people with low time discounting, whereas PHWLs appear most effective among those with low education, suggesting their potential to address education-related disparities. Labeling strategies appeared equally effective across subgroups defined by self-efficacy to quit, quit intention, and health literacy. Combining inserts with PHWLs did not appear to mitigate moderation effects.

IMPLICATIONS

This randomized trial with adults who smoke suggests that cigarette packs with inserts describing cessation benefits and tips can promote cessation-related behaviors (ie, forgoing or stubbing out cigarettes) among those with low-time discounting (ie, low impulsivity). Alternative interventions may be needed for people with high-time discounting, as found in cessation trials. PHWLs appear most effective among those with low education, potentially addressing education-related disparities. No differential effects were found for those with different levels of self-efficacy to quit, quit intentions, or health literacy. Combining inserts and PHWLs may not be more effective than either alone.

Self-reported attention and responses to cigarette package labels at the end of a two-week randomized trial of cigarette package labeling configurations

INTRODUCTION

Cigarette package inserts that describe quitting benefits and tips may promote cessation; however, research is needed to understand better their effects, including potentially enhancing the effects of pictorial health warning labels (PHWLs).

METHODS

A randomized trial with a 2×2 factorial design was conducted with adult smokers (n=356) assigned to either small text-only health warning labels (HWLs; control); inserts with cessation messages, and the small text-only HWLs (inserts-only); large PHWLs (PHWLs-only); both inserts and PHWLs (inserts + PHWLs). Participants received a 14-day supply of their preferred cigarettes with packs labeled to reflect their group. Upon finishing the trial, participants reported their past 14-day frequency of noticing, reading, thinking about smoking harms and cessation benefits, talking about labels, and forgoing cigarettes because of the labels. Ordered logistic models regressed these outcomes on labeling groups, and mediation analyses assessed whether attention (i.e. noticing, reading) to labels mediated effects of labeling exposure on other outcomes (i.e. thinking about harms/benefits, talking, forgoing).

RESULTS

The inserts + PHWLs group reported higher frequencies than the control group for all outcomes. Compared to the control group, both the inserts-only and PHWLs-only groups reported higher frequency of noticing (AOR=3.53 and 2.46, respectively) and reading labels (AOR=2.89 and 1.71), thinking about smoking risks because of the labels (AOR=1.93 and 1.82), and talking about labels (AOR=2.30 and 2.70). Participants in the inserts-only group also reported more frequent thinking about quitting benefits (AOR=1.98). Attention mediated all labeling effects except for the contrast between PHWLs only and control.

CONCLUSIONS

Compared to text-only HWLS, cigarette labeling that involves inserts, PHWLs, or both appears more effective at drawing attention to warnings, which mediated the effects on cessation-related psychosocial and behavioral outcomes.

Messaging about very low nicotine cigarettes (VLNCs) to influence policy attitudes, harm perceptions and smoking motivations: a discrete choice experiment

BACKGROUND

To reduce smoking and the harms it causes, countries, including the USA, are considering policies to reduce nicotine in combustible tobacco to minimally addictive levels. Effective messages about very low nicotine cigarettes (VLNCs) and this policy are crucial in combating misperceptions threatening the policy's effectiveness.

DATA AND METHODS

A discrete choice experiment assessed messages about VLNCs. Participants were 590 adults who smoked exclusively, 379 adults who both smoked and used e-cigarettes, 443 adults who formerly smoked and 351 young adults who never smoked (total n=1763). Seven message attributes were varied systematically (source, harm, chemicals, nicotine, satisfaction, addictiveness and quitting efficacy). Outcomes were selection of messages that generated the most positive attitude towards reduced nicotine policy, the greatest perceived harmfulness of VLNCs, and most strongly motivated quitting and initiating behaviour for VLNCs.

RESULTS

Information about specific harms and chemicals of VLNCs had the largest effects on selection of messages as eliciting more negative attitudes towards VLNCs policy, increasing perceived VLNC harmfulness, increasing motivation to quit VLNCs and decreasing motivation to try VLNCs. Messages with information about quitting efficacy were selected as more motivating to quit among those who smoke, but also more motivating to try VLNCs among those who do not smoke.

CONCLUSION

Harm and chemical information can be prioritised to ensure VLNCs are not misperceived as less harmful than regular cigarettes. Messages about increased quitting efficacy and reduced addictiveness associated with VLNCs may backfire if presented to those who do not smoke.

Combining Inserts With Warning Labels on Cigarette Packs to Promote Smoking Cessation: A 2-Week Randomized Trial

BACKGROUND

Cigarette pack inserts with messages on cessation benefits and advice are a promising labeling policy that may help promote smoking cessation.

PURPOSE

To assess insert effects, with and without accompanying pictorial health warning labels(HWLs), on hypothesized psychosocial and behavioral outcomes.

METHODS

We conducted a 2 × 2 between-subject randomized trial (inserts with efficacy messages vs. no inserts; large pictorial HWLs vs. small text HWLs), with 367 adults who smoked at least 10 cigarettes a day. Participants received a 14-day supply of their preferred cigarettes with packs modified to reflect their experimental condition. Over 2 weeks, we surveyed participants approximately 4-5 times a day during their smoking sessions, querying feelings about smoking, level of worry about harms from smoking, self-efficacy to cut down on cigarettes, self-efficacy to quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported their perceived susceptibility to smoking harms and, for the last 24 hr, their frequency of thinking about smoking harms and cessation benefits, conversations about smoking cessation or harms, and foregoing or stubbing out cigarettes before they finished smoking. Mixed-effects ordinal and logistic models were estimated to evaluate differences between groups.

RESULTS

Participants whose packs included inserts were more likely than those whose packs did not include inserts to report foregoing or stubbing out of cigarettes (OR = 2.39, 95% CI = 1.36, 4.20). Otherwise, no statistically significant associations were found between labeling conditions and outcomes.

CONCLUSIONS

This study provides some evidence, albeit limited, that pack inserts with efficacy messages can promote behaviors that predict smoking cessation attempts.

A mixed-method study of perceptions of cigarette pack inserts among adult smokers from New York and South Carolina exposed as part of a randomized controlled trial

While many countries require prominent pictorial health warning labels (PHWLs) on the outside of cigarette packs to communicate the harms of smoking, there is evidence that cigarette pack inserts that contain efficacy messages may enhance the effectiveness of PHWLs. The US Food and Drug Administration (FDA) has regulatory authority to communicate with smokers through inserts. While current labeling regulations do not require inclusion of inserts, the FDA could implement them in the future. This study assesses US smokers' perceptions of cigarette package inserts at the conclusion of a two-week randomized trial on cigarette labeling where half of participants were exposed to insert messages (two response-efficacy messages and two self-efficacy messages) in their packs. Participants (n = 359) completed a 30- to 60-min interview with both quantitative and qualitative assessments, including measures of recall and perceived message effectiveness (PME) for specific inserts. Correlates of recall and PME were estimated using mixed-effects regression models. Qualitative responses to PME items were analyzed using thematic analysis. Response-efficacy messages had higher PME and recall than self-efficacy messages. People had diverse responses to the inserts, including that they were positive, thought-provoking, and helpful. Reactions to and perceptions of the inserts indicate potential benefits of integrating efficacy messages into labeling policies.

Will tobacco price increases lead more people who smoke to vape? The results from a discrete choice experiment amongst U.S. adults

OBJECTIVE

To understand the extent to which people who smoke, people who vape and nonsmokers would switch between smoking cigarettes and vaping in response to policies (price increases, restrictions on nicotine, places, and information on addictiveness and/or health risks) aimed at decreasing tobacco use by people who smoke and vaping by nonsmokers.

DESIGN

A total of 525 adults aged 18 to 88 years completed a discrete choice survey of 16 choices between two smoking/vaping alternatives. Analysis was conducted using conditional logistic regression for the entire sample and stratified by nonsmokers, people who smoke, and people who vape.

RESULTS

The results suggest that most people who vape also smoke. Nonsmokers were more favorable to vaping and were concerned about long-term health risks and cost associated with vaping. Marginal analysis suggests that price increases will have only modest success in moving people who smoke to start vaping or encouraging people who vape to vape rather than use cigarettes. Nonsmokers are not very sensitive to price changes but are sensitive to information about health impacts.

CONCLUSIONS

Findings indicate that increasing the price of cigarettes would lead to a limited increase in the probability of people who smoke switch to vaping. The study advances our understanding of the views of current nonsmokers toward cigarettes and vaping, suggesting that price increases and increased knowledge of addiction would likely deter nonsmokers from vaping. Changing the amount of nicotine associated with smoking would increase the probability of vaping slightly and have little impact on nonsmokers or vaping preferences, but the most significant change would come from increasing the perceptions of the risk of smoking.

Effects of Modified Tobacco Risk Products with Claims and Nicotine Features on Perceptions among Racial and Ethnic Groups

Research suggests consumers may misunderstand modified risk tobacco product (MRTP) claims. We examined the effects of nicotine content across four tobacco products with and without MRTP claims among a racially and ethnically diverse sample of adults who do and do not smoke. Adults (n = 1484) aged 21-65 completed an online experiment using a 2 × 2 × 4 mixed factorial design to examine the effects of tobacco product (Classic White Snus, IQOS, JUUL e-cigarette, and VLN cigarette) and nicotine content (high vs. low) stratified by MRTP claim (present vs. absent) across four outcomes: (1) likely to try (2) serious disease if used regularly, (3) least addictive, and (4) ease of quitting smoking. Not including an MRTP claim resulted in an increased likelihood of trying a product, decreased concern of serious disease, lower perceived addictiveness, and increased ease of quitting smoking. Participants selected low nicotine IQOS without a claim as the least likely to cause serious disease. Low nicotine JUUL, without a claim, was selected as least addictive and most likely to facilitate quitting. Intentions to try were highest for low nicotine JUUL. Participants selected low-nicotine products as less addictive than high nicotine products. Regulatory efforts should consider how MRTP claims interact with different product characteristics. Subtle differences exist across outcomes between racial and ethnic groups, which indicates that further research is warranted.

An effectiveness-implementation hybrid trial of phone-based tobacco cessation interventions in the Lebanese primary healthcare system: protocol for project PHOENICS

BACKGROUND

Tobacco use remains the leading cause of preventable disease, disability, and death in the world. Lebanon has an exceptionally high tobacco use burden. The World Health Organization endorses smoking cessation advice integrated into primary care settings as well as easily accessible and free phone-based counseling and low-cost pharmacotherapy as standard of practice for population-level tobacco dependence treatment. Although these interventions can increase access to tobacco treatment and are highly cost-effective compared with other interventions, their evidence base comes primarily from high-income countries, and they have rarely been evaluated in low- and middle-income countries. Recommended interventions are not integrated as a routine part of primary care in Lebanon, as in other low-resource settings. Addressing this evidence-to-practice gap requires research on multi-level interventions and contextual factors for implementing integrated, scalable, and sustainable cessation treatment within low-resource settings.

METHODS

The objective of this study is to evaluate the comparative effectiveness of promising multi-component interventions for implementing evidence-based tobacco treatment in primary healthcare centers within the Lebanese National Primary Healthcare Network. We will adapt and tailor an existing in-person smoking cessation program to deliver phone-based counseling to smokers in Lebanon. We will then conduct a three-arm group-randomized trial of 1500 patients across 24 clinics comparing (1) ask about tobacco use; advise to quit; assist with brief counseling (AAA) as standard care; (2) ask; advise; connect to phone-based counseling (AAC); and (3) AAC + nicotine replacement therapy (NRT). We will also evaluate the implementation process to measure factors that influence implementation. Our central hypothesis is that connecting patients to phone-based counseling with NRT is the most effective alternative. This study will be guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, supported by Proctor's framework for implementation outcomes.

DISCUSSION

The project addresses the evidence-to-practice gap in the provision of tobacco dependence treatment within low-resource settings by developing and testing contextually tailored multi-level interventions while optimizing implementation success and sustainability. This research is significant for its potential to guide the large-scale adoption of cost-effective strategies for implementing tobacco dependence treatment in low-resource settings, thereby reducing tobacco-related morbidity and mortality.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05628389, Registered 16 November 2022.

Reasons for Using Roll-Your-Own Tobacco and Perceptions of Health-Promoting Pack Inserts: A Focus Group Study with Roll-Your-Own Tobacco Smokers in Scotland

INTRODUCTION

Use of roll-your-own (RYO) tobacco is increasing in most regions, but few qualitative studies have explored why RYO smokers use this product, and no study has considered their views of health-promoting pack inserts.

METHODS

Eight focus groups were conducted with 18-35-year-old RYO smokers (n = 50) in Greater Glasgow (Scotland) in February-March 2020 to explore reasons for using RYO and perceptions of health-promoting inserts. Participants were shown four inserts adapted from those required in cigarette packs in Canada, with all encouraging quitting, and two RYO-specific inserts explaining that RYO is not less harmful than cigarettes.

RESULTS

Lower price, better taste, the pleasure of rolling and ability to customize roll-ups, and the belief that RYO was less harmful than cigarettes were drivers for use. There were mixed perceptions of the extent to which inserts would capture attention if included in RYO packs. The positive messaging used on the Canadian inserts was considered motivational and inspirational, and contrasted with the on-pack warnings. The messaging on the RYO inserts, in comparison, was viewed unfavorably and generally dismissed. Participants, most of whom were not interested in quitting, did not feel that inserts would lead them to change their smoking behavior. However, some felt that the Canadian inserts could be helpful for those thinking about quitting and young people contemplating smoking.

CONCLUSIONS

Inserts with positive messaging about quitting, rather than messaging explicating the harms of RYO, were preferred by RYO smokers. What, if any, RYO-specific messaging resonates with RYO smokers merits further attention.

IMPLICATIONS

Aside from price, taste, and the pleasure associated with rolling and ability to individualize roll-ups, the erroneous belief that RYO is less harmful than cigarettes was a key reason for use. While inserts with positive messaging about quitting, as used on the Canadian inserts, were viewed as potentially helpful, inserts that challenged the idea that RYO was not less harmful than cigarettes were generally dismissed. Research is needed to understand what types of RYO-specific messaging could most effectively be used on inserts, or indeed in other media, to challenge the misperceptions that many RYO smokers hold.

Why are anti-smoking health-information interventions less effective among low-socioeconomic status groups? A systematic scoping review

ISSUES

This paper identifies and synthesises explanations proposed in the literature for the (in)effectiveness of institutional anti-smoking health-information interventions (HII) among low-socioeconomic status (SES) adults in high-income countries.

APPROACH

We searched eight databases for relevant papers from various disciplines: Studies published in English since 2009, on the effectiveness among low-SES adults of anti-smoking HIIs, aimed at changing knowledge/behaviour, and conducted by official institutions, were included. Through a scoping review, we synthesised: study design, SES indicator, intervention type, intervention source, study population, outcomes, low-SES effects, equity effects, proposed explanations and whether these were studied empirically.

KEY FINDINGS

Thirty-eight studies were included in this scoping review. Seventeen suggested explanations for the (in)effectiveness of the HIIs in low-SES adults, but only nine assessed them empirically. Thematic analysis yielded six themes: message engagement, material conditions, cognition, risk perception, social environment and self-efficacy.

IMPLICATIONS

Explanations for intervention results are not always present, and empirical evidence for explanations is often not provided. Including such explanations and testing their empirical merits in future research can provide the crucial information needed for developing more effective anti-smoking HIIs for low-SES adults.

CONCLUSIONS

To our knowledge, this is the first review to explore the explanations proposed for why anti-smoking HIIs are (in)effective among low-SES adults. It contains insights for future studies aiming to provide empirical evidence on the causes of this (in)effectiveness, and concludes that such research is yet largely missing, but crucial to the quest for more effective and equitable anti-smoking interventions.

Strategies to enhance the effects of pictorial warnings for cigarettes: results from a discrete choice experiment

AIMS

To measure the effects of changing attributes of pictorial health warning labels (HWLs) on cigarette packs in a country that has already implemented pictorial HWLs.

MEASURES

For each choice set, participants were presented with two cigarette packs and asked the following three questions: (1) 'If only these two cigarette packs were available, which would you buy?'; (2) 'Each of these two packs has warnings on the front and back about the health effects of smoking. Which of these warnings best informs you about the dangers from smoking?'; and (3) 'Which warning most makes you think about quitting smoking?'. As recommended for best practices in discrete choice experiments, each of these questions was followed by an 'opt-out' question for participants to indicate whether they really believed there was a difference between the options presented (i.e. 'Would you really choose one of them?'; 'Do you really think that either of these warnings informs you about dangers from smoking?'; or 'Do you really think that either of these warnings would make you think about quitting smoking?', respectively). Each choice set could be viewed for as long as the participant wished. For each choice question (i.e. willingness to buy, informative, motivating to quit), the pack chosen was coded as 1 and the other pack as 0, with both packs being given a value of 0 if the participant 'opted out'.

DESIGN

A within-subject discrete choice experiment that involved systematic manipulation of pictorial HWL size [75 versus 30% (current policy)]; inclusion of imagery on the back of the pack [versus none (current policy)]; and color formatting [black on yellow versus yellow on black (current policy)].

SETTING

Mexico, on-line panel.

PARTICIPANTS

Adult smokers (n = 705).

MEASUREMENTS

For each choice set, participants selected one pack as having the most informative HWL about smoking harms, the one that makes them think the most about quitting and the one they were most willing to buy. We assessed the independent and interactive effects of HWL attributes on choices.

FINDINGS

Larger HWL size on the pack front (75 versus 30%) and inclusion of a pictorial image on the pack back were both independently associated with lower willingness to buy a pack [b = -0.228, standard error (SE) = 0.023 and -0.089, SE = 0.016, respectively] and greater perception of an HWL as informative (b = 0.214, SE = 0.022, and 0.191, SE = 0.017, respectively) and motivating to quit (b = 0.251, SE = 0.023 and 0.194, SE = 0.017, respectively). HWL with black text and yellow background were perceived as less informative (b = -0.037, SE = 0.016) and less motivating to quit (b = -0.032, SE = 0.015) compared with yellow text on a black background.

CONCLUSIONS

Among adult Mexican smokers, pictorial health warning labels on cigarette packages that are larger or cover both sides of the pack appear more effective at lowering purchase intentions and increasing risk perceptions and motivation to quit than smaller health warning labels or health warning labels with imagery only on the pack front.

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

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

Understanding Preferences for Lifestyle-Focused Visual Text Messages in Patients With Cardiovascular and Chronic Respiratory Disease: Discrete Choice Experiment

Background

Supporting healthy lifestyle changes is a key aim of cardiovascular and pulmonary rehabilitation programs. SMS text messaging programs have demonstrated effectiveness in cardiovascular disease risk reduction, weight loss, increasing physical activity, and smoking cessation. The optimization of SMS text messaging programs may deliver greater population benefits as mobile phone use becomes ubiquitous. Visual messaging (ie, image-based messages) has the potential to communicate health messages via digital technology and result in enhanced engagement.

Objective

This study aims to determine and understand patient preferences for lifestyle-focused visual text messages that support cardiovascular and pulmonary rehabilitation.

Methods

A discrete choice experiment was conducted in a 4-stage iterative process to elicit patient preferences for visual message features. Attribute and level development yielded 3 attributes (purpose, image type, and web address), and 16 choice sets were subsequently constructed according to a full factorial design. Patients participating in cardiovascular and pulmonary rehabilitation were surveyed (on the web) for their preferences regarding the visual message choice sets. Respondents were asked to choose among 16 pairs of visual messages regarding key lifestyle behaviors, namely, physical activity and nutrition. The data were analyzed using a conditional logit model.

Results

There was a total of 1728 observations from 54 unique respondents. Two factors that were associated with patient preference were gain-framed purpose compared with no purpose (odds ratio [OR] 1.93, 95% CI 1.40-2.65) and real images compared with cartoon images (OR 1.26, 95% CI 1.04-1.54). A loss-framed purpose was less preferred than no purpose (OR 0.55, 95% CI 0.42-0.74). Overall, patients preferred positive images that were colorful and engaged with text that supported the image and had a preference for images of real people rather than cartoons.

Conclusions

A discrete choice experiment is a scientific method for eliciting patient preferences for a visual messaging intervention that is designed to support changes in lifestyle behaviors. SMS text messaging programs that use visual aids may result in greater patient satisfaction by using a gain frame, using real images, and avoiding a loss frame. Further research is needed to explore the feasibility of implementation and the health and behavioral outcomes associated with such visual messaging programs.

Effects of pictorial warning label message framing and standardized packaging on cigarette packaging appeal among young adult smokers

INTRODUCTION

Pictorial warning labels and standardized "plain" packaging are policy interventions to reduce smoking, in part, by making cigarette packs and smoking less appealing. To inform potential policy decisions, this study examined the relative effects of message text framing (gain vs. loss) and cigarette packaging (standardized vs. branded) on appeal in a sample of young adult cigarette smokers.

METHODS

Cigarette smokers (N = 339) ages 18-30 completed two within-subjects experimental tasks. Tasks assessed the effects of message text framing (gain vs. loss) and packaging (standardized vs. branded) on cigarette packaging appeal. Task 1 was a 2 × 2 discrete choice experiment, where participants chose between each experimental pack and a standard branded cigarette pack without a pictorial warning label. Task 2 was a ranking task where participants ranked all packs on measures of appeal.

RESULTS

In Task 1, there were no significant differences in measures of appeal between packs displaying gain- vs. loss-framed message text, but all packs with pictorial warning labels significantly decreased appeal relative to standard branded packs without pictorial warning labels. Standardized packs with pictorial warning labels significantly reduced appeal relative to branded packs with pictorial warning labels and standard branded packs without pictorial warning labels. Task 2 pack rankings showed similar effects of pictorial warning labels and standardized packaging on appeal.

CONCLUSIONS

Pictorial warning labels with gain- and loss-framed text were equally powerful at reducing appeal of cigarette packs in young adult smokers relative to branded packs without pictorial warning labels, especially when combined with standardized packaging.

Effects of tobacco product type and characteristics on appeal and perceived harm: Results from a discrete choice experiment among Guatemalan adolescents

Guatemala is one of the few countries where both heated tobacco products (HTPs) and electronic cigarettes (e-cigarettes) remain unregulated. We used a discrete choice experiment (DCE) administered to 2038 high school students to assess how tobacco product attributes influence their appeal among Guatemalan adolescents. Participants were randomly assigned to evaluate 4 of 32 contrasting sets, each containing 3 packs (1 of each product type). Experimental manipulations included: product type, brand, nicotine content and flavor. Participants then indicated which product they were most and least interested in trying and would be most and least harmful to their health. Conditional logistic regression models were used to assess the impact of product characteristics on choice. Product type accounted for almost 90% of variation in choices. Respondents were less interested in trying HTPs (B = -0.93; p < 0.001) and viewed them as more harmful (B = 2.77; p < 0.001) compared to cigarettes. They were more interested in trying e-cigarettes (B = 1.22; p < 0.001), which were also perceived as less harmful (B = -1.47; p < 0.001) compared to cigarettes. Products without nicotine were of more interest for trying (B = 0.14; p < 0.001) and perceived as more harmful (B = 0.20; p < 0.001) than those with. Students were more interested in trying a flavor compared to regular tobacco and among the flavors, berry was the highest rated one (B = 0.28; p < 0.001). Finally, in this country with weak tobacco control, e-cigarettes appear to be more appealing and perceived as less harmful than HTPs and cigarettes. Packaging and flavoring regulations are urgently needed on these products as they are a marketing strategy targeting adolescents.

Effectiveness of Cessation Messages Targeting Pregnant and Nonpregnant Female Smokers in the United States: A Cross-Sectional Analysis into the Impact of Pregnancy, Self-Efficacy, and Risk Perception

OBJECTIVES

Roughly 10% of pregnant women are current smokers. Improving smoking cessation in this population before and during pregnancy is essential to prevent adverse fetal outcomes. This study aimed to examine cessation messages targeting American women.

METHODS

An obstetrics-gynecological clinic-based sample of female, current smokers of reproductive age (18-44 years old) was recruited (n = 135) from January to May 2019; half (51.2%) were currently pregnant. Participants completed a within-subjects study with a randomized set of gain- and loss-framed text-only pregnancy-related cessation messages (5 each). Each individual message was rated on a validated, 10-point scale for perceived effectiveness; responses to the seven items were averaged. Regression analyses examined differences in effectiveness ratings by message framing.

RESULTS

Study participants (female smokers) rated the gain-framed messages as slightly more effective than loss-framed messages (7.9 versus 7.7, p < 0.01). After adjusting for quit intention and pregnancy, the relationship between gain- and loss-framing and effectiveness ratings was modified by both self-efficacy and risk perceptions. Women who perceived high risks of smoking during pregnancy had higher effectiveness ratings of both gain- and loss-framed cessation messages, compared to women who perceived low risks. Lower cessation self-efficacy was significantly associated with lower effectiveness ratings for gain- and loss-framed messages (1.53 and 1.92, respectively; p < 0.05).

CONCLUSIONS FOR PRACTICE

Women with lower self-efficacy and low risk perception of smoking risks had the lowered effectiveness ratings for both frames of cessation messages. Enhancing self-efficacy and risk perceptions through clinical interventions may improve the effectiveness of targeted messages to promote quitting smoking before or during pregnancy.

Impact of population tobacco control interventions on socioeconomic inequalities in smoking: a systematic review and appraisal of future research directions

BACKGROUND

While price increases and targeted cessation support have been found to reduce inequalities in smoking by socioeconomic status (SES), evidence on other measures is mixed. We aimed to update the most recent (2014) previous review by identifying and appraising evidence published since 2013 on the equity impact of population tobacco control measures.

METHODS

Systematic searching of 10 electronic databases and hand-searching of four key journals identified 68 primary research articles published since 2013 that sought to examine the equity impact of population tobacco control measures in high-income countries with a negative socioeconomic gradient in smoking. Reported equity impacts were categorised as positive (greater impact among lower SES), neutral (no difference by SES), negative (greater impact among higher SES) or mixed/unclear.

RESULTS

There was substantial growth in research seeking to evaluate the equity impact of tobacco control interventions, but the majority of new studies showed mixed/unclear results. Findings for price increases and targeted cessation support continue to suggest an equity-positive impact, but limitations in the available evidence make further assessment difficult. Substantial differences in the context, scale and implementation of tobacco control policies make straightforward comparison of findings from the previous 2014 and current reviews problematic.

CONCLUSION

Researchers need to adopt more sophisticated, multidisciplinary approaches in evaluating the equity impact of tobacco control measures-developing robust measures of equity effect and using frameworks that take account of context, existing systems/processes and the likely mechanisms of action. Socioeconomic differences in intervention impact within low-income and middle-income countries require evaluation.

Electronic cigarette and moist snuff product characteristics independently associated with youth tobacco product perceptions

INTRODUCTION

Tobacco product characteristics convey product attributes to potential users. This study aimed to assess independent contributions of specific e-cigarette and smokeless tobacco product characteristics to adolescents' perceptions about these products.

METHODS

In 2019-2020, students (N=1003) attending a convenience sample of 7 high schools in California (USA) were individually randomized to one of two discrete choice experiments, featuring either electronic cigarettes (e-cigarettes) or moist snuff. Participants were presented like-product pairs of randomlygenerated hypothetical tobacco products differing in device type, flavor, vapor cloud, and nicotine amount (for e-cigarettes) or differing in brand, flavor, cut, and price (for moist snuff). Within pairs, participants were asked about which product they were more curious, was more dangerous, would give a greater 'buzz,' and would be easier to use. Conditional logistic regression was used to quantify independent associations of product characteristics to participants' choices.

RESULTS

Each e-cigarette and moist snuff characteristic was independently associated with multiple product perceptions. All non-tobacco flavors were associated with more curiosity and perceived ease-of-use but lower perceived danger. Tank and pod-type e-cigarettes were viewed as easier to use and garnered more curiosity than 'cigalike' or 'drip-mod' devices. Smaller vapor cloud e-cigarettes and lower-price moist snuff were viewed as less dangerous, less buzz-inducing, and easier to use. Product ever users held stronger perceptions than never users about device type (e-cigarettes) and brands (moist snuff), while product naïve participants more strongly associated flavor with danger and buzz.

CONCLUSIONS

Tobacco product characteristics convey product attributes to adolescents that may increase appeal. Restricting specific characteristics, including flavors, could reduce positive perceptions of these products among youth.

Smokers' Perceptions of Cigarette Packaging With Audio Warning Messages: A Focus Group Study in Scotland

AIMS

The use of audio pack cues or messages is a recent trend in packaging design. There is scope to use audio technology to communicate health and cessation messages via cigarette packaging. We explored how smokers responded to cigarette packs which played audio health messages.

METHODS

Twenty focus groups were conducted in Scotland in 2015 with smokers (n = 120) segmented by age (16-17, 18-24, 25-35, 36-50, >50), gender and social grade. Perceptions of cigarette packs which played audio warnings were explored, with four messages used: (1) a cessation message with a quitline number, (2) mortality message, (3) fertility message, and (4) message about ageing skin.

RESULTS

Audio warnings were thought to increase message impact, particularly among younger smokers, as they would be hard to ignore or avoid, and repetition may lead to the messages being memorized. The warnings were considered annoying or embarrassing, and participants suggested they may discard the packs and use alternative storage. Some participants suggested that the audio warnings were off-putting and may alter their smoking behavior, with the mortality message deemed most effective and was considered relatable and felt personal. Older smokers were least likely to believe that audio warnings would affect their smoking behavior, although some thought that they may enhance cessation attempts among smokers seeking to quit, and could deter new or potential smokers, for example, young people.

CONCLUSIONS

Cigarette packs with audio messaging may have a role to play, now or in the future, as a novel way of communicating health and cessation information.

IMPLICATIONS

There is a lack of research exploring smokers' perceptions of cigarette packs which play audio health messages. This focus group study provides an understanding of smokers' immediate responses to cigarette packs which played a short health message when opened. Smokers generally viewed them as annoying or embarrassing, and some suggested the use of alternative storage. Audio warnings were thought to increase message salience, memorability, and impact, for younger smokers in particular, and some suggested that they be off-putting for themselves or others.

Roll-your-own smokers' reactions to cessation-efficacy messaging integrated into tobacco packaging design: a sequential mixed-methods study

BACKGROUND

Although loss-framed pictorial warning labels (PWLs) have increased knowledge of the health harms caused by smoking, they may elicit maladaptive responses among some smokers who have tried repeatedly, yet unsuccessfully, to quit smoking. However, research suggests that maladaptive responses may diminish if warnings are complemented with efficacy enhancing messages. Therefore, we explored New Zealand (NZ) adult roll-your-own (RYO) loose tobacco smokers' reactions to self-efficacy and response efficacy messages integrated into the RYO packaging structure and designed to complement PWLs.

DESIGN

We used a sequential mixed-methods design. In-depth interviews gauged participants' (n=22) acceptance of the designs and informed stimuli development for an online survey. The survey (n=785) compared self-efficacy and response efficacy designs to standard Quitline information, and examined agreement with emotions, beliefs and projected behaviours associated with quit attempts.

RESULTS

Our findings suggest placing gain-framed response efficacy messages on the inside flap of RYO tobacco pouches may stimulate specific emotional reactions, beliefs and projected behaviours associated with future quit attempts more effectively than NZ's status quo Quitline information. Those potentially more likely to benefit include smokers who have high baseline response efficacy and who intend to make a quit attempt.

CONCLUSIONS

Integrating cessation-related messaging within tobacco packaging could be a high reach, just-in-time micro-intervention at the point of decision-making. Enhanced efficacy messages could complement and enhance PWLs, and support quitting among groups where smoking prevalence is especially high.

Designing Effective Testimonial Pictorial Warning Labels for Tobacco Products

Warning labels on tobacco products sometimes feature images and stories of real people whose health has been affected by smoking. We examined effects of some of the design elements that may contribute to the effectiveness of these testimonial pictorial warning labels (PWLs). Beginning with a testimonial PWL that contained an image of a person and a basic warning statement (e.g., "Smoking can kill you"), we examined the impact of adding: (a) text detailing the person's name, age and health status (identifiers); and (b) explanatory statements that elaborated on the basic warning using a testimonial or non-testimonial message. In an online experiment, 1255 adult smokers in the United States were randomly assigned to one of six experimental conditions (2 [identifier: none/identifier] × 3 [explanatory statement: none/non-testimonial/testimonial]), or a control condition (text only warning labels that currently appear on packs in the United States). In each condition, participants were exposed to multiple labels each focused on a different health effect. Effectiveness was assessed using emotional responses, engagement and behavioral intentions measured immediately post-exposure, and quit attempts measured at five-week follow up. Testimonial PWLs were more effective than the text only labels. However, there was little evidence that adding identifiers or the explanatory statements enhanced effectiveness; rather, there was some evidence that testimonial explanatory statements reduced effectiveness. These findings suggest that the most effective design for testimonial PWLs may be to combine a basic warning statement with an image of a real person, without any additional textual components.

Exploring the impact of efficacy messages on cessation-related outcomes using Ecological Momentary Assessment

INTRODUCTION

Observational studies indicate that cigarette package inserts with efficacy messages about the benefits of quitting (i.e. response efficacy) and recommendations for successful cessation increase smokers' self-efficacy to quit and promote sustained cessation. However, the effects of inserts with such efficacy messages have not been studied using experimental designs. This study used ecological momentary assessment (EMA) to assess smokers' responses to efficacy inserts.

METHODS

In a randomized case-crossover study among smokers from the United States (n=23), participants received a one-week supply of cigarettes with efficacy inserts and a one-week supply without any inserts, and were randomized to use the packs with inserts on either the first or second week of the study. For 14 consecutive days, participants used a smartphone to answer brief surveys on cessation-related variables during smoking sessions and at the beginning of each day. Multilevel mixed-effects linear and logistic regression models compared responses during the insert period to those of the non-insert period.

RESULTS

The insert period was associated with greater desire to quit (b=0.21, p=0.012), motivation to quit (b=0.18, p=0.001), self-efficacy to cut down (b=0.26, p<0.001) and to quit (b=0.28, p<0.000), and response efficacy/perceived benefits of quitting (b=0.13, p=0.012). Insert exposure was not significantly associated with forgoing cigarettes (OR=1.9, p=0.2).

CONCLUSIONS

Results from this EMA study suggest that inserts with efficacy messages may promote determinants of smoking cessation. This is consistent with observational research in Canada, which is the only country to use inserts with efficacy messages as well as pictorial warnings about smoking risks on the outside of packs. Future studies should assess the extent to which efficacy inserts can not only be used to communicate health information to smokers but also work in synergy with pictorial warnings.

The impact of flavors, health risks, secondhand smoke and prices on young adults' cigarette and e-cigarette choices: a discrete choice experiment

AIMS

To estimate young adults' preferences for cigarettes and e-cigarettes, and how preferences vary by policy-relevant factors. A related aim was to provide information on potential substitution/complementarity across cigarettes and e-cigarettes ahead of policy selection.

DESIGN

An online discrete choice experiment (DCE) in which respondents chose their preferred option among cigarettes, two types of e-cigarettes (disposable/reusable) and 'none'. Each cigarette-type was characterized by policy-relevant attributes: flavors, short-term health risks to self, secondhand smoke risks and price. A latent class model identified smoking types that respond differently to these.

SETTING

US tobacco market.

PARTICIPANTS

A total of 2003 young adults (aged 18-22 years) who ever tried either cigarettes or e-cigarettes, recruited via the survey platform Qualtrics, matched to the 2015 National Health Interview Survey by age, gender, education and census region.

MEASUREMENTS

Respondents' DCE choices.

FINDINGS

Young adults fell into two broad categories. One latent group, termed 'prefer smoking group', preferred cigarettes and another, 'prefer vaping group', preferred e-cigarettes. The 'prefer smoking group' preferred lower prices and lower health harms more than other attributes. The 'prefer vaping group' valued these, although price less intensely, and valued health and fruit/candy flavors more.

CONCLUSION

Banning all flavors in cigarettes and e-cigarettes might improve the health of young adults who ever tried either cigarettes or e-cigarettes. Young adult ever-triers might be deterred from smoking by increasing cigarette prices and encouraged to switch to e-cigarettes by reducing the health harms of e-cigarettes. Reducing health harms of e-cigarettes could also make the 'prefer vaping group' less likely to quit, resulting in increased health harm.

Testing Cessation Messages for Cigarette Package Inserts: Findings from a Best/Worst Discrete Choice Experiment

This study assessed smokers' responses to different smoking cessation topics and imagery for cigarette package inserts. Adult smokers from Canada (n = 1000) participated in three discrete choice experiments (DCEs): DCE 1 assessed five cessation benefit topics and five imagery types; DCE 2 assessed five messages with tips to improve cessation success and five imagery types; DCE 3 assessed four reproductive health benefits of cessation topics and four imagery types. In each DCE, participants evaluated four or five sets of four inserts, selecting the most and least motivating (DCEs 1 & 3) or helpful (DCE 2) for quitting. Linear mixed models regressed choices on insert and smoker characteristics. For DCE 1, the most motivating messages involved novel disease topics and imagery of younger women. For DCE 2, topics of social support, stress reduction and nicotine replacement therapy were selected as most helpful, with no differences by imagery type. For DCE 3, imagery influenced choices more than topic, with imagery of a family or a mom and baby selected as most motivating. Statistically significant interactions for all three experiments indicated that the influence of imagery type on choices depended on the message topic. Messages to promote smoking cessation through cigarette pack inserts should consider specific combinations of message topic and imagery.