Prevalence and correlates of flavored novel oral nicotine product use among a national sample of youth

BACKGROUND

Flavored novel oral nicotine products (ONP), such as pouches, gum, lozenges, tablets, and gummies, have recently entered the US market but have not been authorized for smoking cessation. This study assessed the prevalence and correlates of ONPs in a national sample of youth who smoked little filtered cigars or cigarillos (LCCs) or were susceptible to LCCs.

METHODS

We conducted a national online survey from September-October 2022, as part of a study to develop cigar warnings among youth. Those aged 15-20 years old who reported using (ever or current) or susceptibility to little filtered cigars or cigarillos (LCCs) were eligible. Descriptive statistics and chi-square analyses assessed the prevalence of flavored ONP use and associations with other past 30-day tobacco product use and participant characteristics.

RESULTS

Approximately one-fifth (17.1 %) of the sample (n = 680) reported past month flavored ONP use. Any past month tobacco use was correlated with past month flavored ONP use (ps < 0.001), increasing from 17.1 % in the overall sample to 26.8 % among those reporting e-cigarette use, 41.4 % (LCCs), 47.8 % (waterpipe tobacco), 61.8 % (large cigars), and 69.1 % (smokeless tobacco). The number of products used in the past month was significantly associated with higher odds of ONPs in the past month in a multivariable logistic regression model (aOR2.26; 95 % CI: 1.92, 2.65).

DISCUSSION

Almost one-fifth of participants who use or are susceptible to cigar use in our national sample of youth use ONPs. Dual/poly use of other tobacco products and ONPs among youth suggests that many of these youth may be addicted to nicotine. Additional surveillance and regulation of ONPs that exhibit enticing characteristics, such as flavors, kid-friendly formulations, and targeted marketing/branding may be needed.

Analysis of Candy Tobacco Imitation Products Available Online in the United States

INTRODUCTION

Youth tobacco use remains a critical public health concern, and childhood use of candy tobacco imitation products (CTIP) is associated with cigarette use among youth. However, no research has examined the full extent of CTIP available for purchase in the United States.

AIMS AND METHODS

We conducted a content analysis of CTIP available on English-language, US-based websites. We identified sites that marketed CTIP utilizing Google and candy retail websites, examining each product for product names, the tobacco product being replicated (eg, cigar and cigarette), manufacturer, candy flavor, images, product rating, pack color, and if the product had packaging that may appeal to youth.

RESULTS

We found 66 CTIP available. The most popular CTIP were cigars, with 39 separate products (59%), followed by candy cigarettes-14 products (21%), candy pipes-8 products (12%), and chewing tobacco-5 products (8%). In the 52 products where packaging design was available, 39 (75%) had packaging that may appeal to youth.

CONCLUSIONS

CTIP, many of which contain packaging appealing to youth, are widely available for purchase online across the United States. These findings could stimulate policy actions, such as removal of CTIP from popular retail websites, labeling of CTIP as potentially dangerous to youth, or age verification requirements for purchasing CTIP.

IMPLICATIONS

CTIP continues to be sold on the internet despite research indicating candy cigarette product use by youth increases their likelihood of smoking. We conducted research to understand the extent to which CTIP are sold on the internet and whether these products are being marketed to youth. The results provide evidence that some of the largest retail companies in the world continue to sell CTIP, and the majority are sold in packaging that likely appeals to youth. The results suggest that further research into the market for these products is needed, and regulatory measures should be considered to prevent CTIP from leading to youth tobacco use.

Awareness and Perceptions of US Food and Drug Administration's JUUL Marketing Denial Order: A National Study of US Adolescents

INTRODUCTION

We examined awareness and perceptions of the US Food and Drug Administration (FDA) JUUL marketing denial order (MDO) that occurred in June 2022 among a nationally representative sample of US adolescents.

AIMS AND METHODS

Data were collected in August 2022 via an online survey (n = 1603). Adolescents were asked whether they had heard about the JUUL MDO, and, if yes, where they heard the news. Those who had heard were asked about the MDO's impact on their harm beliefs about JUUL and vape products in general. We examined correlates of awareness of the MDO and of increased JUUL and vape harm perceptions.

RESULTS

Twenty-seven percent of adolescents had heard about the MDO. Older adolescents (adjusted odds ratio [aOR] = 1.13) and LGBTQ+ adolescents (aOR = 2.05) had significantly higher odds of having heard the news, while those who identified as Black or African American had significantly lower odds of having heard (aOR = 0.56). Most participants who were aware of the MDO indicated that they had higher harm perceptions about JUUL itself (77.9%) and vapes in general (79.6%). Youths susceptible to vaping and current users were less likely to report increased harm perceptions about JUUL (B = -0.34 and -0.46, respectively) and vapes in general (B = -0.27 and -0.43) compared with youth not susceptible to vaping.

CONCLUSIONS

The results of this nationally representative survey demonstrate that over one-quarter of US youth heard about the JUUL MDO and the vast majority of those indicated increased harm perceptions about vapes. Large-scale news events about vaping can reach youth audiences and may impact what youth think about the harms of vaping.

IMPLICATIONS

Analysis of a nationally representative survey of adolescents aged 13-17 revealed that more than 25% had heard about the marketing denial order issued to JUUL Labs by the FDA in June of 2022. We also found that the vast majority of adolescents reported increased JUUL and vape harm perceptions in response to hearing about the MDO. This indicates that news coverage about vaping-including coverage of regulatory actions-can reach and potentially impact adolescents. It is therefore important to monitor news coverage about vaping, how it is framed and discussed across media platforms, and its reach among priority populations.

Perceived Effectiveness of Cigar Warnings in Discouraging Blunt Use

INTRODUCTION

Many people remove the tobacco leaf from cigars and replace it with cannabis (ie, blunts), but few studies have examined whether messages about the risks of cigars, like warnings on cigar packages, can affect blunt use.

METHODS

Participants were 438 U.S. adults who reported past 30-day cigar use and ever blunt use, recruited from a probability-based national panel to take an online survey. In a 2 × 2 experiment with a between-subjects design, we manipulated two cigar warning characteristics: (1) warning type: text-only versus pictorial (ie, text + image) and (2) warning size: 30% (smaller) versus 50% (larger) of the product package. Participants then viewed six different warnings on a fictious cigarillo package, within their randomly assigned condition. After evaluating all stimuli, participants were asked the extent to which the warnings discouraged them from wanting to use cigars to smoke cannabis (ie, blunt perceived warning effectiveness). Response options ranged from "not at all" (1) to "a great deal" (5).

RESULTS

We observed no main effects of warning type or size on blunt perceived warning effectiveness. However, a significant interaction existed between the two experimental manipulations (p = .009). Whereas adding images made no difference to blunt perceived warning effectiveness when warnings were smaller (simple effect: -0.22, p = .28), images mattered for larger warnings. Specifically, adding images increased blunt perceived warning effectiveness when warnings were 50% of the product package (simple effect: 0.52, p = .008).

CONCLUSIONS

This experiment provides preliminary evidence that larger pictorial cigar warnings may discourage blunt use relative to larger but text-only warnings.

IMPLICATIONS

Blunts, which are hollowed out cigars with tobacco leaf wrappers that are filled with cannabis leaf, are one of the most common ways in which tobacco and cannabis are used simultaneously, yet few studies have examined whether messages about the risks of cigars can affect blunt use. We conducted an online experiment concerning the perceived effectiveness of cigar warnings among people who use blunts recruited from a probability-based panel. Results provide novel, preliminary evidence that larger pictorial cigar warnings may discourage blunt use, relative to larger but text-only warnings. More research evaluating cigar warnings on blunt use is needed.

Perceived message effectiveness of cigar warning themes among adults in the United States

Most tobacco warnings focus on health harms to the consumer, but other message themes may be promising. We assessed perceived message effectiveness (PME) among adults who smoke cigars for 12 cigar warning statements to discourage smoking, and measured PME across four message themes: explicit health effects to the consumer, secondhand smoke effects, chemicals/constituents, and toxicity. Between April 23 and May 7, 2020, we conducted an online study with U.S. adults who used any cigar type in the past 30 days (n = 777). Participants were randomly assigned to view two out of 12 warnings and rate each one on PME. We analyzed PME mean ratings (range 1 [low] to 5 [high]). The warning statements for lung cancer (M = 3.91) and heart disease (M = 3.77) had the highest PME ratings; secondhand smoke (M = 3.50) and formaldehyde (M = 3.48) had the lowest PME ratings. Multilevel analyses showed that the explicit health effects theme was associated with higher PME ratings compared to other warning themes (ps < 0.05 for chemicals/constituents and secondhand smoke effects) except toxicity (p =.16). Higher awareness of consequences was associated with higher PME ratings (p <.001). Higher nicotine dependence was also associated with higher PME ratings (p = .004). Warning statements with information addressing the themes of health harms and toxicity could potentially inform those who smoke cigars about the broader harms of cigar use and should be considered in FDA labeling regulations for cigars.

Improving Point-of-Sale Warnings for Single Cigars: Implications for Premium Cigars

INTRODUCTION

For cigars sold individually without packaging, including many premium cigars, the US Food and Drug Administration (FDA) proposed that retailers display six warning statements on a sign at the point-of-sale (POS).

AIMS AND METHODS

To examine the potential effectiveness of cigar warning signs, we conducted a between-subjects online experiment. Participants were 809 U.S. adults who reported using cigars (78% ever large cigar use, 49% past 30-day large cigar use) recruited from a probability-based panel. Participants viewed an image of a cigar store countertop with randomization to one of four conditions: (1) no warning sign, (2) a sign with six FDA proposed text-only warnings, (3) a sign with six novel text-only warnings, or (4) a sign with six novel text + image warnings. We used analysis of variance (ANOVA) models and post hoc Tukey tests to examine the results.

RESULTS

The FDA-proposed text-only warning sign was perceived as less effective in discouraging participants from smoking cigars (M: 3.26, SD: 1.39; scale range: 1-5, where five indicates higher discouragement) compared with the novel text-only warning sign (M = 3.38, SD = 1.40) and the novel text + image warning sign (M = 3.65, SD = 1.34). The novel text + image warning sign increased discouragement from smoking cigars versus the FDA-proposed text-only warning sign (p = .02) and decreased the perceived satisfaction of smoking cigars versus no warning sign (p = .04). In a sensitivity analysis, the novel text + image warning sign decreased the perceived satisfaction of smoking cigars (p = .01), decreased cigar purchase intentions (p = .03), decreased the urge to smoke (p = .03), and increased discouragement from smoking cigars (p = .006) compared with all other study conditions.

CONCLUSIONS

Results provide new evidence that policymakers, such as the FDA, could use when proposing POS warning signs for cigars.

IMPLICATIONS

The US FDA proposed that retailers display a warning sign at the POS for cigars sold individually without packaging. We conducted an online experiment concerning the potential effectiveness of this regulatory policy with people who use cigars recruited from a probability-based panel. Results provide the first evidence that the FDA-proposed text-only warning sign was perceived as less effective than other types of warning signs and that adding images could potentially increase the effectiveness of warning signs. These findings are particularly relevant for premium cigars, which are often sold individually in brick-and-mortar retail settings.

Objective and perceived measures of tobacco marketing are uniquely associated with cigar use

BACKGROUND

Few studies have examined associations between perceived and objective exposure to tobacco marketing and cigar use, which is the second most commonly used tobacco product by youth.

METHODS

We used Geographic Ecological Momentary Assessment data over 14 days from youth aged 16-20 years (n=83 participants, n=948 observations; 34% past month users of any tobacco product) in eight city areas in California. Tobacco outlets in study cities were visited by trained observers to record outlet Global Positioning System (GPS) point locations and outdoor tobacco marketing. We assessed daily perceived exposure to tobacco marketing within participants' activity spaces; daily objective exposure to tobacco outlets with outdoor marketing within 50 m of activity space polylines (number of outlets and time spent near outlets) and daily cigar use excluding and including blunts.

RESULTS

Controlling for demographics and baseline tobacco use, results from mixed logistic regression models showed that greater perceived exposure to tobacco marketing was positively associated with higher odds of cigar use each day, excluding blunts (adjusted odds ratios (aOR): 2.00; 95% CI 1.03 to 3.87) and including blunts (aOR: 1.87; 95% CI 1.26 to 2.77). Also, exposure to a greater number of tobacco outlets with outdoor marketing was associated with higher odds of cigar use each day, excluding blunts (aOR: 1.34; 95% CI 1.01 to 1.78), but not including blunts.

CONCLUSIONS

Tobacco control efforts should consider both perceived and objective exposure to tobacco marketing and unique associations with blunt use to prevent cigar use.

Synthetic nicotine descriptors: awareness and impact on perceptions of e-cigarettes among US youth

BACKGROUND

Electronic cigarettes (e-cigarettes) are being advertised and sold with synthetic nicotine. Little research has examined youth awareness of synthetic nicotine or the impact of synthetic nicotine descriptors on perceptions of e-cigarettes.

METHODS

Participants were a sample of 1603 US adolescents (aged 13-17 years) from a probability-based panel. The survey assessed knowledge of nicotine source in e-cigarettes (from 'tobacco plants' or 'other sources besides tobacco plants') and awareness of e-cigarettes containing synthetic nicotine. Then, in a between-subjects experiment with a 2×3 factorial design, we manipulated descriptors on e-cigarette products: (1) nicotine label (inclusion of the word 'nicotine': present or absent) and (2) source label (inclusion of a source: 'tobacco-free', 'synthetic' or absent).

RESULTS

Most youth were either unsure (48.1%) or did not think (20.2%) that nicotine in e-cigarettes comes from tobacco plants; similarly, most were unsure (48.2%) or did not think (8.1%) that nicotine in e-cigarettes comes from other sources. There was low-to-moderate awareness of e-cigarettes containing synthetic nicotine (28.7%), with higher awareness among youth who use e-cigarettes (48.0%). While no main effects were observed, there was a significant three-way interaction between e-cigarette status and the experimental manipulations. The 'tobacco-free nicotine' descriptor increased purchase intentions relative to 'synthetic nicotine' (simple slope: 1.20, 95% CI 0.65 to 1.75) and 'nicotine' (simple slope: 1.20, 95% CI 0.67 to 1.73) for youth who use e-cigarettes.

CONCLUSIONS

Most US youth do not know or have incorrect beliefs about the sources of nicotine in e-cigarettes and describing synthetic nicotine as 'tobacco-free nicotine' increases purchase intentions among youth who use e-cigarettes.

How do current tobacco warnings compare to the WHO FCTC guidelines: a content analysis of combustible tobacco warnings worldwide

OBJECTIVE

Many countries have adopted warning labels for combustible tobacco products, yet little research exists describing tobacco warning characteristics globally and to what extent they meet the WHO Framework Convention for Tobacco Control (FCTC) Guidelines. This study evaluates characteristics of combustible tobacco warnings.

DESIGN

We conducted a content analysis to describe the overall landscape of warnings using descriptive statistics and compared to the WHO FCTC Guidelines.

SETTING

We searched existing warning databases for combustible tobacco warnings from English-speaking countries. We compiled warnings meeting inclusion criteria and coded for message and image characteristics using a pre-defined codebook.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Characteristics of combustible tobacco warning text statements and warning images were the primary study outcomes. There were no secondary study outcomes.

RESULTS

We identified a total of 316 warnings from 26 countries or jurisdictions worldwide. Of these warnings, 94% included warning text and an image. Warning text statements most often described health effects to the respiratory (26%), circulatory (19%) and reproductive systems (19%). Cancer was the most frequently mentioned health topic (28%). Fewer than half of warnings included a Quitline resource (41%). Few warnings included messages about secondhand smoke (11%), addiction (6%) or cost (1%). Of warnings with images, most were in colour and showed people (88%), mostly adults (40%). More than 1 in 5 warnings with images included a smoking cue (ie, cigarette).

CONCLUSIONS

While most tobacco warnings followed WHO FCTC guidance on effective tobacco warnings, such as communicating health risks and inclusion of images, many did not include local Quitline or cessation resources. A sizeable minority include smoking cues that could inhibit effectiveness. Full alignment with WHO FCTC guidelines will improve warnings and better achieve the WHO FCTC objectives.

Diabetes distress mediates the relationship between depressive symptoms and glycaemic control among adults with type 2 diabetes: Findings from a multi-site diabetes peer support intervention

AIMS

Diabetes distress is positively associated with HbA_1c and may mediate the relationship between depressive symptoms and HbA_1c . This study examined these relationships in a geographically, socioeconomically, and ethnically diverse sample of adults with type 2 diabetes.

METHODS

Using data from five US sites evaluating peer support for diabetes management (n = 917), Structural Equation Modeling (SEM) examined whether diabetes distress (four items from Diabetes Distress Scale) mediated the relationship between depressive symptoms (PHQ-8) and HbA_1c . Sites compared interventions of varying content and duration with control conditions. Time from Baseline Assessment to Final Assessment varied from six to 18 months. Site characteristics were controlled by entering site as a covariate along with age, sex, education, diabetes duration, insulin use, and intervention/control assignment.

RESULTS

Depressive symptoms, diabetes distress, and HbA_1c were all intercorrelated cross-sectionally and from Baseline to Final Assessment (rs from 0.10 to 0.57; ps <0.05). In SEM analyses, diabetes distress at Final Assessment mediated the relationship between Baseline depressive symptoms and HbA_1c at Final Assessment (indirect effect: b = 0.031, p < 0.001), controlling for Baseline HbA_1c and covariates. Parallel analysis of whether depressive symptoms mediated the relationship between Baseline diabetes distress and HbA_1c at Final Assessment was not significant.

CONCLUSIONS

In this diverse sample, diabetes distress mediated the influence of depressive symptoms on HbA_1c but the reverse, depressive symptoms mediating the effect of distress, was not found. These findings add to the evidence that diabetes distress is a worthy intervention target to improve clinical status and quality of life among individuals with type 2 diabetes.

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

INTRODUCTION

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

AIMS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Communicating the risks of tobacco and alcohol co-use

BACKGROUND

While tobacco and alcohol co-use is highly prevalent across the United States, little experimental research has examined ways to counter such dual use. We developed and tested messages about the risks of co-using tobacco and alcohol among adults who used a combustible tobacco product and drank alcohol within the 30 days.

METHODS

In an online experiment, 1,300 participants were randomly assigned to read different messages about tobacco and alcohol co-use (e.g., Alcohol and tobacco cause throat cancer). Three between-subjects experiments manipulated the presence of: 1) a marker word (e.g., Warning), 2) text describing the symptoms of health effects and a quitting self-efficacy cue, and 3) an image depicting the health effect. Participants rated each message using a validated Perceived Message Effectiveness (PME) scale. We used independent samples t-tests to examine differences between experimental conditions. Results include effect sizes (Cohen's d) to compare standardized mean differences.

RESULTS

Our sample was 64% male, 70% white, 23% Black, and 17% Hispanic/Latino with a mean age of 42.4 (SD = 16.4) years. Messages that described the symptoms of the health effect (d = 0.17, p = 0.002) and included an image (d = 0.11, p = 0.04) were rated significantly higher in PME compared with messages that did not describe symptoms and were text-only. We found no significant effects of a marker word or self-efficacy cue on PME.

CONCLUSIONS

Messages that describe the symptoms of health effects and include text and images may be particularly effective for communicating the risks of tobacco and alcohol co-use and decreasing adverse health effects from co-use.

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.

A Mixed Methods Approach to Improving Provider Counseling of Patients Who Vape

Significance

Vaping is an epidemic among young people, but there is little guidance on how medical providers should counsel young adults about vaping. To address this gap, we examined how electronic health record (EHR) systems prompt providers to collect vaping data and interviewed young adults about vaping communications with providers and preferred information sources.

Methods

In this mixed methods study, we used survey research methods to explore if prompts exist in EHR systems to guide discussions about vaping with youth seen in primary care. We collected primary care practice information about EHR prompts regarding e-cigarette use from 10 rural North Carolina practices from August 2020 through November 2020 and interviewed 17 young adults (age 18-21 years) who reviewed resources and provided their opinion on the resource's relevance for their age group. Interviews were stratified by vaping status, transcribed, coded, and thematically analyzed.

Results

Only 5 of 10 EHR systems included prompts to capture information about vaping and data capture was optional in all 5 cases. Of the 17 interviewees, 10 were female, 14 were White, 3 were non-White and the mean age was 19.6 years. Two central themes emerged. Young adults: 1) were open to confidential, non-confrontational interactions with trusted providers and supported the use of a 2-page resource/discussion guide, questionnaires about vaping, and other waiting room resources, and 2) wanted prevention and cessation resources to be age-appropriate, including medical facts from a trusted source, and to be disseminated via social media platforms used by young adults.

Conclusions

We found a lack of EHR functionalities in screening for vaping status hindered patients from receiving counseling on use. Young adults report a willingness to communicate with and learn from trusted providers and to gain understanding from information accessed via social media.

A Heart Healthy Intervention Improved Tobacco Screening Rates and Cessation Support in Primary Care Practices

We examined whether an evidence-based cardiovascular disease risk reduction intervention (Heart Health Now) would improve rates for tobacco cessation screening and counseling in small primary care practices in North Carolina. Heart Health Now was a stepped wedge, stratified, cluster randomized trial for primary care practices that were staffed by 10 or fewer clinicians and had an electronic health record. The Heart Health Now intervention consisted of education tools, onsite practice facilitation for one year, and a practice-specific cardiovascular population management dashboard that included monthly, measure-specific run charts to help guide quality improvement. Our primary outcomes were practice-level rates of tobacco screening and tobacco cessation support-extracted from practices' electronic health records-and measured at pre-intervention and 6 months post-intervention. The 28 practices included in our analyses represented 78,120 patients and 17,687 smokers. Significant change occurred in practices' tobacco screening rates and cessation support rates over time. From pre- to post-intervention, screening rates significantly increased from 82.7 to 96.2% (p < 0.001). Similarly, cessation support rates significantly increased from 44.3 to 50.1% (p = 0.03). Several practice-level factors were associated with improvement including being in an academic health center or faculty practice, having more clinicians, and having a lower percentage of White patients. In conclusion, a multi-component intervention focused on multiple cardiovascular disease risk reduction in multiple small primary care practices successfully improved rates of tobacco screening and cessation support.

Impact of an e-cigarette tax on cigarette and e-cigarette use in a middle-income country: a study from Indonesia using a pre-post design

OBJECTIVES

Indonesia implemented its first e-cigarette regulation in 2018, a 57% tax on the retail price of e-cigarette liquid (e-liquid), exceeding the 40% average tax on cigarettes. Economic research suggests that this tax could unintentionally increase cigarette smoking among dual users, but this has not been examined in a low-income or middle-income country. We therefore investigated the effects of the e-liquid tax among adults in Indonesia.

DESIGN

Pre-post study.

SETTING

Indonesia.

PARTICIPANTS

Adults who currently used e-cigarettes and either currently or occasionally smoked cigarettes or recently quit were recruited using Facebook and Instagram ads. Our follow-up response rate was 79%. A final sample of 1039 adults participated.

PRIMARY OUTCOME MEASURES

E-cigarette and cigarette use.

RESULTS

Following the e-liquid tax, participants reported paying a 4.4% higher price for e-liquid (p=0.02). Participants also reported an average 0.5-day decrease in the number of days they used e-cigarettes in the past week (p<0.001), and the proportion of daily e-cigarette users decreased (75.9% to 63.6%; p<0.001). Overall, reported use of cigarettes also declined, on average, by nine cigarettes per week. Participants who reported decreasing their e-cigarette use had higher odds of reporting increasing their cigarette use rather than reporting no change (adjusted OR: 2.99; 95% CI: 1.95 to 4.59). Further, as participants reported using e-cigarettes less frequently, they reported using cigarettes more frequently (β=-2.41, p=0.007).

CONCLUSIONS

Following an e-liquid tax in Indonesia, prices of e-liquid increased slightly, e-cigarette and cigarette use declined, and people who reported decreasing their e-cigarette use reported increasing their cigarette use. To avoid encouraging cigarette use, a prudent approach would be to raise cigarette taxes concurrently with e-cigarette taxes.

Youth tobacco and cannabis use and co-use: Associations with daily exposure to tobacco marketing within activity spaces and by travel patterns

BACKGROUND

We investigated youth daily activity spaces, travel patterns, exposure to tobacco retail marketing, and tobacco and cannabis use and co-use.

METHODS

Data included 1,060 daily assessments from 100 participants (16-20 years old) in 8 California cities. Using GPS-enabled smartphones with a survey application, youth completed brief daily surveys, and location coordinates were obtained at one-minute intervals. Tobacco outlets in study cities were visited by observers to record outlet GPS point locations and data concerning tobacco marketing. Tobacco outlet addresses and GPS location coordinates were geocoded. Activity spaces were constructed by joining sequential location points. Measures included the number of outlets with outdoor tobacco marketing within 50 m of activity space polylines and the amount of time participants were within 50 m of these outlets each day. Participants also reported tobacco and cannabis use and whether they saw tobacco ads by their neighborhood, school, workplace, and anywhere else each day. Additionally each day they reported how much time they traveled by different modes of transportation, with parents/guardians, and with friends.

RESULTS

In mixed effects multinomial regression models, perceived exposure to tobacco marketing was associated with co-use of tobacco and cannabis on a given day (RRR = 1.66, p < 0.05). Although perceived exposure to tobacco marketing was not associated with tobacco use only, moderation analysis indicated that the likelihood of tobacco use was greater among youth who walked/biked/skated more (RRR = 5.22, p < 0.05).

CONCLUSION

Perceived exposure to tobacco marketing contributes to youth tobacco and cannabis use or co-use, especially for those who travel by walking/biking/skating.

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.

Complementarity of Digital Health and Peer Support: “This Is What’s Coming”

Purpose

This study examined integration of peer support and a Food and Drug Administration-cleared, diabetes management app (DMA) in diabetes self-management support as a scalable model for those with type 2 diabetes mellitus (T2DM).

Methods

Two lay health Coaches delivered telephone-based self-management support to adults (N = 43) with T2DM recruited through a primary group practice. Those eligible were offered no-cost access to DMA for the entire 6-month study. Coaches introduced DMA and contacted individuals by phone and text with frequency dependent on participant needs/preferences. DMA supported monitoring of blood glucose, carbohydrate intake, and medication use, as well as messaging personalized to participants’ medication regimens. Clinical data were extracted from DMA, electronic medical records, and Coaches’ records. Structured interviews of 12 participants, 2 Coaches, and 5 project staff were analyzed using deductive pre-identified codes (regarding adoptability, patterns of use, value added, complementarity, and sustainability) utilizing standard procedures for qualitative analysis.

Results

Of the 43 participants, 38 (88.4%) enrolled in DMA. In general, participants used both DMA and lay health coaches, averaging 144.14 DMA entries (structured, e.g., medications, and free form, e.g., “ate at a restaurant” and “stressed”) and 5.86 coach contacts over the 6-month intervention. Correlation between DMA entries and coach contacts (r = .613, p &lt; 0.001) was consistent with complementarity as were participants’ and coaches’ observations that (a) DMA facilitated recognition of patterns and provided reminders and suggestions to achieve self-management plans, whereas (b) coaching provided motivation and addressed challenges that emerged. Mean hemoglobin A1c (A1c) declined from 9.93% to 8.86% (p &lt; 0.001), with no pattern of coaching or DMA use significantly related to reductions. Staff identified resources to coordinate coach/DMA interventions as a major sustainability challenge.

Conclusions

DMA and peer support for diabetes management are compatible and complementary. Additional practice integration research is needed for adoption and scale-up.

Youth Exposure to Warnings on Cigar, E-Cigarette, and Waterpipe Tobacco Packages

INTRODUCTION

Studies of tobacco product warnings have focused primarily on the reach and effectiveness of cigarette warnings for adult smokers, whereas few observational studies have examined noncigarette tobacco product warnings among youth.

METHODS

High school students from the 2019 National Youth Tobacco Survey (n=10,094) reported the frequency of exposure to warnings on cigar, e-cigarette, and waterpipe tobacco packages and the perceived harm of occasionally using e-cigarettes and waterpipe tobacco. In 2020, results were analyzed for the entire sample and among subgroups, including never users, ever users, youth susceptible to using tobacco, and current users.

RESULTS

Reported high exposure to warnings was highest for cigars (22.3%), followed by that for e-cigarettes (20.8%) and that for waterpipe tobacco (7.0%). Youth who were susceptible to using cigars (AOR=1.53, 95% CI=1.29, 1.82), who ever used cigars (AOR=4.32, 95% CI=3.57, 5.22), or who currently used cigars (AOR=8.90, 95% CI=6.95, 11.39) were more likely to report high exposure to cigar warnings than youth who never used cigars. Similar findings were observed for e-cigarette and waterpipe tobacco warnings. For youth who ever used e-cigarettes, high exposure to warnings was associated with higher odds of perceiving e-cigarettes as harmful for occasional product use (AOR=1.50, 95% CI=1.05, 2.15), and high exposure to waterpipe tobacco warnings was associated with higher odds of perceiving waterpipe tobacco as harmful (AOR=1.21, 95% CI=1.00, 1.45).

CONCLUSIONS

Warnings on noncigarette tobacco products reach some youth at risk for using these products, but these warnings may need to be strengthened to further reduce their use.

How Are Neighborhood Characteristics Associated With Mental and Physical Functioning Among Older Adults With Radiographic Knee Osteoarthritis?

OBJECTIVE

To examine how neighborhood characteristics are associated with health outcomes among older adults with osteoarthritis.

METHODS

In multilevel, cross-sectional, and longitudinal analyses we examined whether 4 neighborhood characteristics were associated with depressive symptoms and reported knee impact scores, and whether the neighborhood characteristics interacted with race/ethnicity among older adults with radiographic knee osteoarthritis (n = 656 for cross-sectional analyses and n = 434 for longitudinal analyses). The data came from the Johnston County Osteoarthritis Project, a prospective cohort study in North Carolina designed to examine risk factors for osteoarthritis.

RESULTS

Although few longitudinal associations were found, cross-sectional results suggested that greater perceived neighborhood social cohesion (B = -0.04, P < 0.001) and perceived neighborhood resources for physical activity and walking (B = -0.03, P < 0.001) were associated with fewer depressive symptoms, and that greater perceived neighborhood resources for physical activity and walking were associated with higher (better) knee impact scores (B = 0.48, P = 0.008). We also observed 2 significant interactions among neighborhood characteristics and race/ethnicity related to depressive symptoms (P < 0.01); for African American adults, greater perceived neighborhood resources for physical activity and walking were associated with fewer depressive symptoms (B = -0.03, P < 0.001), but for White adults, greater perceived neighborhood safety was associated with fewer depressive symptoms (B = -0.04, P = 0.003).

CONCLUSION

In a sample of older adults with radiographic knee osteoarthritis, neighborhood context mattered, but in nuanced ways. Interventions aiming to improve mental and physical functioning of older adults with knee osteoarthritis can look to this study as evidence for the importance of neighborhood characteristics.

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.

Youth daily exposure to tobacco outlets and cigarette smoking behaviors: does exposure within activity space matter?

AIMS

To examine whether daily exposure to tobacco outlets within activity spaces is associated with cigarette smoking and with the number of cigarettes smoked by youth that day.

DESIGN

The study used geographic ecological momentary assessment (GEMA) data that combined daily surveys with ecological momentary assessment of global positioning systems (GPS) using geographic information systems (GIS) to allow for real-time data collection of participants' environments and behaviors.

SETTING

Eight mid-sized California (USA) city areas.

PARTICIPANTS

The analytical sample included 1065 days, which were clustered within 100 smoker and non-smoker participants (aged 16-20 years, 60% female).

MEASUREMENTS

Any cigarette smoking and number of cigarettes smoked on a given day, the number of tobacco outlets within 100 m of activity space polylines each day, the number of minutes participants spent within 100 m of tobacco outlets each day and demographic characteristics (age, sex, race/ethnicity and perceived socio-economic status).

FINDINGS

Controlling for demographic characteristics, the findings of multi-level mixed effects logistic models were inconclusive, whether or not the number of tobacco outlets within 100 m of youths' activity space polylines or the number of minutes spent within 100 m of tobacco outlets were associated with whether the participant smoked cigarettes on a given day [odds ratio (OR) = 1.05, P = 0.24; OR = 0.99, P = 0.81, respectively]. However, in multi-level zero-inflated negative binomial models, the risk of smoking an additional cigarette on a given day increased with each additional tobacco outlet [incidence rate ratio (IRR) = 1.04, P < 0.05] and each additional minute spent within 100 m of tobacco outlets (IRR = 1.01, P < 0.001) each day.

CONCLUSIONS

Among young people in urban California, differences in day-to-day exposure to tobacco outlets within activity spaces does not seem to be significantly associated with whether a person smokes a cigarette on a given day, but higher exposure to tobacco outlets appears to be positively associated with the number of cigarettes smoked on that day.

Tobacco Quit Intentions and Behaviors among Cigar Smokers in the United States in Response to COVID-19

Combustible tobacco users appear to be at greater risk for serious complications from COVID-19. This study examined cigar smokers' perceived risk of COVID-19, quit intentions, and behaviors during the current pandemic. We conducted an online study between 23 April 2020 to 7 May 2020, as part of an ongoing study examining perceptions of different health effects of cigars. All participants used cigars in the past 30 days (n = 777). Three-quarters of the sample (76.0%) perceived they had a higher risk of complications from COVID-19 compared to non-smokers. The majority of participants (70.8%) intended to quit in the next six months due to COVID-19, and almost half of the sample (46.5%) reported making a quit attempt since the start of the COVID-19 pandemic. Far more participants reported increasing their tobacco use since COVID-19 started (40.9%) vs. decreasing their tobacco use (17.8%). Black or African American participants, participants who reported using a quitline, and participants with higher COVID-19 risk perceptions had higher intentions to quit using tobacco due to COVID-19, and higher odds of making a quit attempt since COVID-19 started. More research is needed to understand how tobacco users are perceiving COVID-19 risks and changing their tobacco use behaviors.

How Is Exposure to Tobacco Outlets Within Activity Spaces Associated With Daily Tobacco Use Among Youth? A Mediation Analysis

INTRODUCTION

We investigated associations between exposure to tobacco outlets within activity spaces and daily tobacco use, and whether exposure to adults or peers using tobacco mediate these relationships.

METHODS

We used Geographic Ecological Momentary Assessment data over 14 days from 85 youth aged 16-20 years in eight mid-sized California city areas. Tobacco outlet addresses and global positioning systems locations were geocoded and activity spaces were constructed by joining sequential points. We assessed daily number of tobacco outlets within 50 or 100 m of activity space polylines and number of minutes participants were within 50 or 100 m of tobacco outlets each day; daily use of tobacco; and whether participants saw (1) adults and (2) people their age (peers) using tobacco each day.

RESULTS

Controlling for demographics, results of multilevel structural equation models showed no association between number of tobacco outlets within 50 m of polylines and tobacco use (probit regression coefficient: 0.01, p = .82). However, we found evidence of an indirect effect (p = .001) through daily exposure to peers using tobacco. Specifically, greater number of tobacco outlets within 50 m of polylines was positively associated with seeing peers use tobacco (probit regression coefficient: 0.10, p < .001). In turn, seeing peers use tobacco was positively associated with tobacco use on that day (probit regression coefficient: 2.23, p < .001). Similar results were found for number of tobacco outlets within 100 m of polylines.

CONCLUSIONS

Exposure to tobacco outlets within activity spaces affects youth tobacco use through daily exposure to peers who use tobacco.

IMPLICATIONS

Using real-time-ordered data, this article examines whether exposure to adults and peers using tobacco mediate associations between exposure to tobacco outlets within activity spaces and daily tobacco use among youth. Results suggest that exposure to tobacco outlets within activity spaces affects daily tobacco use through exposure to peers who use tobacco. These findings provide additional significant support for policy makers who are considering regulating the number and density of tobacco retailers and point to the importance of interventions focused on peer tobacco use and youths' daily environments to reduce tobacco use.

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.

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.

Youth source of acquisition for E-Cigarettes

As rates of traditional cigarette smoking have decreased among youth over the past several years, rates of e-cigarette use have increased. Little evidence exists on how youth obtain e-cigarettes. We used data from middle and high school students under the age of 18 who reported using an e-cigarette in the past 30 days from the 2017 North Carolina Youth Tobacco Survey (n = 640). We used chi-square tests and multivariable logistic regressions to examine correlates of access and place of acquisition. Over half (51.5%) of youth report acquiring e-cigarettes from a friend. Youth in 12th grade had higher odds of acquiring e-cigarettes from a vape shop (aOR: 2.54, 95% CI: 1.25, 5.15) or retail outlet (aOR: 2.40, 95% CI: 1.18, 4.90) than youth in middle school. Compared to non-Hispanic white youth, Hispanic youth had lower odds of acquiring e-cigarettes from a vape shop (aOR: 0.42, 95% CI: 0.20, 0.87). Youth living with someone who uses e-cigarettes, compared to those who did not, had higher odds of acquiring e-cigarettes from a family member (aOR: 3.95, 95% CI: 1.94, 8.05). Finally, current smokers had higher odds of acquiring e-cigarettes from a retail outlet (aOR: 3.28, 95% CI: 1.88, 5.70) and lower odds of acquiring e-cigarettes from a friend (aOR: 0.53, 95% CI: 0.36, 0.77). Youth primarily reported obtaining e-cigarettes from a friend. Living with someone who uses e-cigarettes may be a risk factor for acquiring e-cigarettes from family members. Identifying sources of e-cigarette acquisition will help inform interventions preventing youth e-cigarette access.

Impact of non-menthol flavours in e-cigarettes on perceptions and use: an updated systematic review

OBJECTIVES

Given the exponential increase in the use of e-cigarettes among younger age groups and in the growth in research on e-cigarette flavours, we conducted a systematic review examining the impact of non-menthol flavoured e-cigarettes on e-cigarette perceptions and use among youth and adults.

DESIGN

PubMed, Embase, PyscINFO and CINAHL were systematically searched for studies published and indexed through March 2018.

ELIGIBILITY CRITERIA

Quantitative observational and experimental studies that assessed the effect of non-menthol flavours in e-cigarettes on perceptions and use behaviours were included. Specific outcome measures assessed are appeal, reasons for use, risk perceptions, susceptibility, intention to try, initiation, preference, current use, quit intentions and cessation.

DATA EXTRACTION AND SYNTHESIS

Three authors independently extracted data related to the impact of flavours in tobacco products. Data from a previous review were then combined with those from the updated review for final analysis. Results were then grouped and analysed by outcome measure.

RESULTS

The review included 51 articles for synthesis, including 17 published up to 2016 and an additional 34 published between 2016 and 2018. Results indicate that non-menthol flavours in e-cigarettes decrease harm perceptions (five studies) and increase willingness to try and initiation of e-cigarettes (six studies). Among adults, e-cigarette flavours increase product appeal (seven studies) and are a primary reason many adults use the product (five studies). The role of flavoured e-cigarettes on smoking cessation remains unclear (six studies).

CONCLUSION

This review provides summary data on the role of non-menthol flavours in e-cigarette perceptions and use. Consistent evidence shows that flavours attract both youth and adults to use e-cigarettes. Given the clear findings that such flavours increase product appeal, willingness to try and initiation among youth, banning non-menthol flavours in e-cigarettes may reduce youth e-cigarette use. Longitudinal research is needed to examine any role flavours may play in quit behaviours among adults.

Believability of Cigarette Warnings About Addiction: National Experiments of Adolescents and Adults

Introduction

We conducted two experiments to examine the believability of three addiction-focused cigarette warnings and the influence of message source on believability among adolescents and adults in the United States.

Methods

Experimental data were collected using national phone surveys of adolescents (age 13-17; n = 1125; response rate, 66%) and adults (age 18+; n = 5014; response rate, 42%). We assessed the believability of three cigarette warnings about addiction attributed to four message sources (Food and Drug Administration [FDA], Surgeon General, Centers for Disease Control and Prevention [CDC], no source).

Results

The majority of adolescents and adults reported the three cigarette warnings were very believable (49%-81% for adolescents; 47%-76% for adults). We found four to five times higher odds of adolescents believing a warning that cigarettes are addictive (warning 1) or that nicotine was an addictive chemical (warning 2) compared to a warning that differentiated the addictive risks of menthol versus traditional cigarettes (warning 3), warning 1 adjusted odds ratio (aOR): 4.53, 95% confidence interval (CI): 3.10, 6.63; warning 2 aOR: 3.87, 95% CI: 2.70, 5.50. Similarly, we found three to five times higher odds of adults (including current smokers) believing the same warnings, warning 1 aOR: 3.74, 95% CI: 2.82, 4.95; warning 2 aOR: 3.24, 95% CI: 2.45, 4.28. Message source had no overall impact on the believability of warnings for either population.

Conclusions

Our findings support the implementation of FDA's required warnings that cigarettes are addictive and that nicotine is an addictive chemical. These believable warnings may deter adolescents from initiating smoking and encourage adults to quit smoking.

Implications

This article describes, for the first time, the believability of different cigarette warnings about addiction. We now know that the majority of adolescents and adults believe cigarette warnings that highlight cigarettes as addictive and that nicotine is an addictive chemical in tobacco. However, a warning that highlighted the relative risk of addiction for menthol cigarettes compared to traditional cigarettes was not as believable among either population. Our findings support the implementation of FDA's required warnings that cigarettes are addictive and that nicotine is an addictive chemical that may deter adolescents from initiating smoking and encourage adults to quit smoking.

Vaping cannabis among adolescents: prevalence and associations with tobacco use from a cross-sectional study in the USA

OBJECTIVE

Previous research suggests that some adolescents are using e-cigarette devices to vaporise ('vaping') cannabis in the form of hash oil, tetrahydrocannabinol (THC) wax or oil, or dried cannabis buds or leaves. However, it is unclear how adolescents who vape cannabis use other tobacco products. This study examined the extent to which adolescents reported ever vaping cannabis and investigated how demographic variables and tobacco behaviours were associated with use.

DESIGN

We used cross-sectional data from adolescents (total response rate 64.5%) who participated in the 2017 North Carolina Youth Tobacco Survey. SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights.

SETTING

North Carolina, USA.

PARTICIPANTS

Adolescents in high school (n=2835).

PRIMARY OUTCOME AND MEASURE

Adolescents were asked to indicate whether they had ever used an e-cigarette device with marijuana, THC or hash oil, or THC wax.

RESULTS

Approximately 1 in 10 high school students reported ever vaping cannabis in the overall sample (9.6%). In multivariable models, adolescents who reported using cigars (adjusted OR (aOR) 3.76, 95% CI 2.33 to 6.07), waterpipe (aOR 2.32, 95% CI 1.37 to 3.93) or e-cigarettes (aOR 3.18, 95% CI 2.38 to 4.25) in the past 30 days had higher odds of reporting ever vaping cannabis compared with their counterparts. There was no significant association between use of smokeless tobacco (aOR 0.89, 95% CI 0.42 to 1.91) or use of cigarettes (aOR 1.27, 95% CI 0.71 to 2.29) in the past 30 days and odds of reporting ever vaping cannabis.

CONCLUSIONS

These findings provide evidence that large numbers of high school students who use tobacco products have vaped cannabis. As tobacco control policies-such as communication campaigns or smoke-free laws-increasingly focus on e-cigarettes, attention to understanding how adolescents use e-cigarettes to vape substances other than nicotine is essential.

Enhancing Community-Based Participatory Research Through Human-Centered Design Strategies

Introduction. The purpose of this review is to compare and contrast the values, purpose, processes, and outcomes of human-centered design (HCD) and community-based participatory research (CBPR) approaches to address public health issues and to provide recommendations for how HCD can be incorporated into CBPR partnerships and projects. Review Process. By consulting published literature, source materials, and experts on both approaches, a team of researchers completed a three-phased process of synthesizing key similarities and differences between HCD and CBPR and generating recommendations for ways to integrate HCD strategies in CBPR projects. Results. There are five HCD strategies that can be readily incorporated into CBPR projects to improve outcomes: (1) form transdisciplinary teams, (2) center empathy, (3) recruit and work with "extreme users," (4) rapidly prototype, and (5) create tangible products or services. Conclusions. Integrating HCD in CBPR projects may lead to solutions that potentially have greater reach, are more readily adopted, are more effective, and add innovation to public health services, products, and policies.

Do Smokers Recall Source or Quitline on Cigarette Constituent Messages?

OBJECTIVES

The Food and Drug Administration (FDA) is required under the Family Smoking Prevention and Tobacco Control Act to communicate the risks of tobacco use to the public. Little research exists about methods to communicate the constituents of tobacco in a media campaign. This research examines specific strategies to increase effectiveness of a media campaign for cigarette smoking adults about tobacco constituents by including engagement text about smoking cessation and FDA as the source of the campaign.

METHODS

In an eye tracking study of 211 current cigarette smokers, participants randomly viewed 4 cigarette constituent messages that varied engagement text for quitting (benefits of quitting and quitline number, presence, absence) and by FDA source (presence, absence). After the eye tracking session, participants were asked about recall of the national quitline number and the source of message.

RESULTS

Participants in conditions with engagement text were significantly more likely than those in the no engagement conditions to recall the national quitline number. Few participants saw or recalled the FDA source.

CONCLUSIONS

Engagement text for smoking cessation on constituent communication campaign messages significantly increases recall of the quitline, an important resource for smokers.

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

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

How is neighborhood social disorganization associated with diabetes outcomes? A multilevel investigation of glycemic control and self-reported use of acute or emergency health care services

Background

Diabetes management is influenced by a number of factors beyond the individual-level. This study examined how neighborhood social disorganization (i.e., neighborhoods characterized by high economic disadvantage, residential instability, and ethnic heterogeneity), is associated with diabetes-related outcomes.

Methods

We used a multilevel modeling approach to investigate the associations between census-tract neighborhood social disorganization, A1c, and self-reported use of acute or emergency health care services for a sample of 424 adults with type 2 diabetes.

Results

Individuals living in neighborhoods with high social disorganization had higher A1c values than individuals living in neighborhoods with medium social disorganization (B = 0.39, p = 0.01). Individuals living in neighborhoods with high economic disadvantage had higher self-reported use of acute or emergency health care services than individuals living in neighborhoods with medium economic disadvantage (B = 0.60, p = 0.02).

Conclusions

High neighborhood social disorganization was associated with higher A1c values and high neighborhood economic disadvantage was associated with greater self-reported use of acute or emergency health care services. Controlling for individual level variables diminished this effect for A1c, but not acute or emergency health care use. Comprehensive approaches to diabetes management should include attention to neighborhood context. Failure to do so may help explain the continuing disproportionate diabetes burden in many neighborhoods despite decades of attention to individual-level clinical care and education.

Trial registration

For this study, we used baseline data from a larger study investigating the impacts on patient-centered outcomes of three different approaches to self-monitoring of blood glucose among 450 adults with non-insulin dependent type 2 diabetes living in North Carolina. This study was registered as a clinical trial on 1/7/2014 (https://clinicaltrials.gov/ct2/show/NCT02033499).

Trends and Racial Disparities in Mono, Dual, and Poly Use of Tobacco Products Among Youth

Introduction

We examined racial disparities in mono, dual, and poly use of tobacco products including whether racial disparities changed over time.

Methods

We analyzed data on high school students from the North Carolina Youth Tobacco Survey collected in 2011, 2013, and 2015. Dual and poly use included use of two and three or more tobacco products, respectively, in the past month. Multinomial regression models assessed racial differences and changes over time in mono, dual, and poly use. Data include product combinations most commonly used by youth from different racial groups.

Results

In total, 24% (in 2011) and 26% (in 2013 and 2015) of students used tobacco products. No significant changes over time were observed in mono (12%) or dual use (6%). Poly use was 6%, 8%, and 7% in 2011, 2013, and 2015, respectively. Relative to nonuse of tobacco, White students had a higher relative risk than Blacks for mono use. Whites and Hispanics had a higher relative risk than Blacks for dual and poly use. Observed racial differences in tobacco use did not change over time. Types of tobacco products used varied by year and race. In 2015, e-cigarette was the most commonly used product among mono users from all racial groups.

Conclusions

Substantial racial variation persists over time in mono and multiple tobacco product use among North Carolina youth, including racial variation in the types of tobacco products used. Research and policy efforts should examine and eliminate factors that drive multiple tobacco use and racial disparities in use among youth.

Implications

This study reports on racial disparities in mono and multiple tobacco product use among youth. White and Hispanic youth have higher relative risk for dual and poly use of tobacco products than Black youth. In addition, significant racial variation exists in the types of tobacco products used among youth mono, dual, and poly users, with cigarettes, cigars, smokeless tobacco, and e-cigarettes being the most commonly used products. Patterns of multiple tobacco product use vary by race and may warrant tailored prevention efforts. Strengthening tobacco control regulations for other tobacco products than cigarettes is critical to reduce multiple tobacco product use among youth.

Correction to: Mental Health in China: Stigma, Family Obligations, and the Potential of Peer Support

The original version of this article unfortunately contained a mistake in "Funding" section. The funding information for Dr. Li is missing in the original publication. The corrected Funding section is given below.

A Cluster-Randomized Trial of a Mobile Produce Market Program in 12 Communities in North Carolina: Program Development, Methods, and Baseline Characteristics

BACKGROUND

Mobile markets are an increasingly popular method for providing access to fresh fruits and vegetables (F/V) in underserved communities; however, evaluation of these programs is limited, as are descriptions of their development, study designs, and needs of the populations they serve.

OBJECTIVE

Our aim was to describe the development and theoretical basis for Veggie Van (VV), a mobile produce market intervention, the study design for the VV evaluation, and baseline characteristics of the study population.

DESIGN

The protocol and sample for a cluster-randomized controlled trial with 12 sites are described.

PARTICIPANTS/SETTING

Community partner organizations in the Triangle region of North Carolina that primarily served lower-income families or were located in areas that had limited access to fresh produce were recruited. Eligible individuals at each site (older than 18 years of age, self-identified as the main shoppers for their household, and expressed interest in using a mobile market) were targeted for enrollment. A total of 201 participants at 12 sites participated in the VV program and evaluation, which was implemented from November 2013 to March 2016.

MAIN OUTCOME MEASURES

Change in F/V intake (cups/day), derived from self-reported responses to the National Cancer Institute F/V screener, was the main outcome measure.

STATISTICAL ANALYSES PERFORMED

We performed a descriptive analysis of baseline sample characteristics.

RESULTS

Mean reported F/V intake was 3.4 cups/day. Participants reported generally having some access to fresh F/V, and 57.7% agreed they could afford enough F/V to feed their family. The most frequently cited barriers were cost (55.7%) and time to prepare F/V (20.4%). Self-efficacy was lowest for buying more F/V than usual and trying new vegetables.

CONCLUSIONS

By addressing cost and convenience and building skills for purchasing and preparing F/V, the VV has the potential to improve F/V consumption in underserved communities.

E-Cigarette Use Among Adolescents Not Susceptible to Using Cigarettes

Introduction

Research suggests that adolescents who use electronic cigarettes (e-cigarettes), including adolescents not susceptible to smoking cigarettes (ie, those who have never smoked cigarettes and are not attitudinally susceptible to using cigarettes), are more likely to initiate using cigarettes or other combustible tobacco products than adolescents who do not use e-cigarettes. In this study, we examined correlates of e-cigarette use and susceptibility among adolescents not susceptible to future cigarette smoking.

Methods

We used data on high school students from the 2015 North Carolina Youth Tobacco Survey (n = 1,627). SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights.

Results

Increasing perceived harm of e-cigarettes was associated with lower odds of susceptibility to using e-cigarettes (adjusted odds ratio [AOR] = 0.79; 95% confidence interval [CI], 0.65–0.96) and current use of e-cigarettes (AOR = 0.43; 95% CI, 0.25–0.72). Similar patterns were found for perceived harm of secondhand e-cigarette vapor. Exposure to e-cigarette vapor in indoor or outdoor public places was positively associated with susceptibility to using e-cigarettes (AOR = 1.96; 95% CI, 1.33–2.91) and with current e-cigarette use (AOR = 5.69; 95% CI, 2.57–12.61).

Conclusion

To prevent initiation of e-cigarette use, particularly among adolescents not susceptible to smoking cigarettes, educational campaigns could target harm perceptions associated with e-cigarettes. In addition, regulations that limit adolescents’ exposure to e-cigarettes in public places may decrease e-cigarette use by nonsusceptible adolescents.

Attitudes towards Potential New Tobacco Control Regulations among U.S. Adults

Favorable attitudes towards tobacco control policies can facilitate their implementation and success. We examined attitudes toward four potential U.S. Federal tobacco regulations (banning menthol from cigarettes, reducing nicotine levels in cigarettes, banning candy and fruit flavored electronic cigarettes, and banning candy and fruit flavored little cigars and cigarillos) and associations with individual and state variables. A nationally representative phone survey of 4337 adults assessed attitudes toward potential policies. Weighted logistic regression was used to assess relationships between attitudes and demographic factors, smoking behavior, beliefs about the government (knowledge, trust, and credibility), exposure to tobacco control campaigns, and state variables from the US Centers for Disease Control and Prevention (CDC) State Tobacco Activities Tracking and Evaluation (STATE) System. Most respondents supported three out of four policies. Respondents that were female, non-white, Latino, living below the poverty line, had less than high school education, were of older age, did not smoke, had higher trust in government, and were exposed to national tobacco control campaigns had higher odds of expressing favorable attitudes toward potential new tobacco regulations than did their counterparts. No state-level effects were found. While differences in attitudes were observed by individual demographic characteristics, behaviors, and beliefs, a majority of participants supported most of the potential new tobacco regulations surveyed.

Should the Legal Age for Tobacco Be Raised? Results From a National Sample of Adolescents

Raising the minimum age of legal access to tobacco products may reduce smoking initiation and save lives. In a national telephone survey (2014–2015), US adolescents aged 13 to 17 years (N = 1,125; response rate, 66%) were asked about raising the age of legal access to tobacco products and randomized to hear one of 3 ages (19, 20, or 21 y). Most adolescents, across all US regions, favored raising the minimum age of legal access to 19 (75.7%), 20 (80.6%), or 21 (76.4%). These supportive attitudes may be useful to tobacco prevention and control practitioners who seek to reduce tobacco use among adolescents.

Are Some of the Cigar Warnings Mandated in the U.S. More Believable Than Others?

Background: Text warnings are mandated on cigars sold in the United States (U.S.), however little published research has examined effectiveness of cigar warnings. This is the first study examining the believability of cigar warnings among adults in the U.S. Methods: Adults in the U.S. (n = 5014) were randomized in a phone survey to receive one of three cigar-specific mandated warning messages ("Cigar smoking can cause cancers of the mouth and throat, even if you do not inhale", "Cigar smoking can cause lung cancer and heart disease", and "Cigars are not a safe alternative to cigarettes") with one of four warning sources (no source, Surgeon General, CDC (Centers for Disease Control and Prevention), FDA (Food and Drug Administration)). Results: Most adults found the cigar warnings very believable (66.9%). Weighted logistic regression results indicate that the message "Cigar smoking can cause lung cancer and heart disease" was associated with higher odds of being very believable (AOR: 2.05, 95% CI: 1.55, 2.70) and the message "Cigars are not a safe alternative to cigarettes" was associated with lower odds of being very believable (AOR: 0.71, 95% CI: 0.55, 0.92) compared to the message "Cigar smoking can cause cancers of the mouth and throat, even if you do not inhale". Warning source had no impact on believability. Conclusions: We tested three of the currently mandated cigar warnings in the U.S. and found significant differences in believability between them. Further research on cigar warnings may improve communication to the public on cigar health risks, ultimately preventing uptake of cigars and promoting cessation among cigar users.

Believability of new diseases reported in the 2014 Surgeon General's Report on smoking: Experimental results from a national survey of US adults

BACKGROUND

Tobacco use is the leading cause of preventable disease and death globally. The 2014 Surgeon General's Report included new diseases linked to smoking, including liver and colon cancer, diabetes and tuberculosis. As more diseases are linked to smoking, which diseases should we communicate to the public and what message source has the most impact?

METHODS

Data were collected through a nationally representative phone survey of US adults (N=5014), conducted from September 2014 through May 2015. We experimentally randomized participants to a 2 (new smoking disease messages - liver and colon cancers compared to diabetes and tuberculosis) by 4 (message sources - CDC, FDA, Surgeon General, and none) experiment. The outcome was message believability.

RESULTS

About half the sample was female (51.5%) and 17.8% were a current smoker. Overall, 56% of participants said the messages were very believable. Cancer messages (liver and colon cancer) were significantly more believable than messages about chronic disease (tuberculosis and diabetes), 61% vs. 52%. Smokers were less likely to report both sets of new disease messages as very believable compared to non-smokers. Significantly more smokers intending to quit (44.5%) found the messages to be very believable compared to smokers not intending to quit (22.6%). Believability did not differ by message source.

CONCLUSION

Important differences exist in believability of disease messages about new tobacco-related information. Messages emphasizing the causal link between smoking and new diseases should be considered for use in mass media campaigns.

Awareness and trust of the FDA and CDC: Results from a national sample of US adults and adolescents

Trust in government agencies plays a key role in advancing these organizations' agendas, influencing behaviors, and effectively implementing policies. However, few studies have examined the extent to which individuals are aware of and trust the leading United States agencies devoted to protecting the public’s health. Using two national samples of adolescents (N = 1,125) and adults (N = 5,014), we examined demographic factors, with a focus on vulnerable groups, as correlates of awareness of and trust in the Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), and the federal government. From nine different weighted and adjusted logistic regression models, we found high levels of awareness of the existence of the FDA and CDC (ranging from 55.7% for adolescents’ awareness of the CDC to 94.3% for adults’ awareness of the FDA) and moderate levels of trust (ranging from a low of 41.8% for adults’ trust in the federal government and a high of 78.8% for adolescents’ trust of the FDA). In the adolescent and adult samples, awareness was higher among non-Hispanic Blacks and respondents with low numeracy. With respect to trust, few consistent demographic differences emerged. Our findings provide novel insights regarding awareness and trust in the federal government and specific United States public health agencies. Our findings suggest groups to whom these agencies may want to selectively communicate to enhance trust and thus facilitate their communication and regulatory agendas.

Perceptions and Experiences with Flavored Non-Menthol Tobacco Products: A Systematic Review of Qualitative Studies

Although a few countries have banned flavored cigarettes (except menthol), flavors in most tobacco products remain unregulated across the globe. We conducted a systematic review of qualitative studies examining perceptions of and experiences with flavored non-menthol tobacco products. Of 20 studies on flavored tobacco products included in our qualitative systematic review, 10 examined hookah, six examined e-cigarettes, two examined little cigars and cigarillos (LCCs), and three examined other tobacco products, including cigarettes. The majority of studies, regardless of product type, reported positive perceptions of flavored tobacco products, particularly among young adults and adolescents. In six studies that assessed perceptions of harm (including hookah, LCCs, and other flavored tobacco products), participants believed flavored tobacco products to be less harmful than cigarettes. In studies that examined the role of flavors in experimentation and/or initiation (including three studies on e-cigarettes, one hookah study and one LCC study), participants mentioned flavors as specifically leading to their experimentation and/or initiation of flavored tobacco products. Given that many countries have not yet banned flavors in tobacco products, these findings add to existing research on why individuals use flavored tobacco products and how they perceive harm in flavored tobacco products, providing further support for banning non-menthol flavors in most tobacco products.

Public attitudes toward larger cigarette pack warnings: Results from a nationally representative U.S. sample

A large body of evidence supports the effectiveness of larger health warnings on cigarette packages. However, there is limited research examining attitudes toward such warning labels, which has potential implications for implementation of larger warning labels. The purpose of the current study was to examine attitudes toward larger warning sizes on cigarette packages and examine variables associated with more favorable attitudes. In a nationally representative survey of U.S. adults (N = 5,014), participants were randomized to different warning size conditions, assessing attitude toward "a health warning that covered (25, 50, 75) % of a cigarette pack." SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights. Across experimental groups, nearly three-quarters (72%) of adults had attitudes supportive of larger warning labels on cigarette packs. Among the full sample and smokers only (N = 1,511), most adults had favorable attitudes toward labels that covered 25% (78.2% and 75.2%, respectively), 50% (70% and 58.4%, respectively), and 75% (67.9% and 61%, respectively) of a cigarette pack. Young adults, females, racial/ethnic minorities, and non-smokers were more likely to have favorable attitudes toward larger warning sizes. Among smokers only, females and those with higher quit intentions held more favorable attitudes toward larger warning sizes. Widespread support exists for larger warning labels on cigarette packages among U.S. adults, including among smokers. Our findings support the implementation of larger health warnings on cigarette packs in the U.S. as required by the 2009 Tobacco Control Act.

Believability of Cigar Warning Labels Among Adolescents

PURPOSE

Despite high rates of cigar use among youth, little information exists about how cigar warnings are received by youth. We examined believability of different cigar warning messages with different sources among adolescents in a national phone survey.

METHODS

Adolescents (aged 13-17 years) in the US (N = 1,125; total response rate, 66%) were randomized to receive one of three health messages ("cigar smoking can cause cancers of the mouth and throat, even if you do not inhale," "cigar smoking can cause lung cancer and heart disease," and "cigars are not a safe alternative to cigarettes") and one of four warning sources (Food and Drug Administration, Surgeon General, Centers for Disease Control and Prevention, and no source). Believability was assessed with "how believable is this warning," and responses were dichotomized for "not at all or somewhat" versus "very."

RESULTS

Weighted logistic regression results indicated that most youth found the cigar warnings very believable (60.5%). Messages about mouth and throat cancer (regardless of inhalation) and the safety of cigars in comparison to cigarettes were rated as significantly less believable than messages about lung cancer and heart disease related to cigars. There were no significant differences by source or other demographics. However, youth susceptible to using cigarettes were less likely to report the cigar warnings to be very believable.

CONCLUSIONS

The messages of cigar warning labels are not viewed as equally believable among adolescents. Future studies should examine how youth process messages about health effects of cigars and the impact of different cigar warnings on youth experimentation with and use of cigars.

Key Features Of Peer Support In Chronic Disease Prevention And Management

Peer support from community health workers, promotores de salud, and others through community and health care organizations can provide social support and other assistance that enhances health. There is substantial evidence for both the effectiveness and the cost-effectiveness of peer support, as well as for its feasibility, reach, and sustainability. We discuss findings from Peers for Progress, a program of the American Academy of Family Physicians Foundation, to examine when peer support does not work, guide dissemination of peer support programs, and help integrate approaches such as e-health into peer support. Success factors for peer support programs include proactive implementation, attention to participants' emotions, and ongoing supervision. Reaching those whom conventional clinical and preventive services too often fail to reach; reaching whole populations, such as people with diabetes, rather than selected samples; and addressing behavioral health are strengths of peer support that can help achieve health care that is efficient and of high quality. Challenges for policy makers going forward include encouraging workforce development, balancing quality control with maintaining key features of peer support, and ensuring that underresourced organizations can develop and manage peer support programs.