Global cancer stigma research: a U.S. National Cancer Institute workshop report.

Stigma is a social process characterized by negative beliefs, attitudes, and stereotypes associated with a specific attribute or characteristic that leads to discrimination and social exclusion. Stigma manifests across the cancer control continuum and remains a key challenge for cancer prevention and control worldwide. In this commentary, we provide an overview of the U.S. National Cancer Institute's (NCI) Global Cancer Stigma Research Workshop, a multi-disciplinary international conference held virtually in September 2022, which focused on the intersection of cancer and stigma. The meeting was unique in its convening of researchers, advocates, clinicians, and non-governmental and governmental organizations, who-as a collective-provided overarching topics, cross-cutting considerations, and future directions for the cancer stigma research community to consider, which we describe herein. In summary, studying cancer stigma comprehensively requires a holistic, adaptive, and multifaceted approach-and should consider interrelated factors and their intersection within diverse cultural and social contexts worldwide. Collectively, there was a call for: an inclusive approach, encouraging researchers and practitioners to identify and measure cancer stigma as a driver for cancer health inequities globally; an expansion of existing research methodology to include diversity of experiences, contexts, and perspectives; and collaborations among diverse stakeholders to develop more effective strategies for reducing stigma and improving cancer outcomes. Such efforts are essential to cultivating effective and equitable approaches to preventing and treating cancer worldwide.

Perceptions of Health Misinformation on Social Media: Cross-Sectional Survey Study.

BACKGROUND: Health misinformation on social media can negatively affect knowledge, attitudes, and behaviors, undermining clinical care and public health efforts. Therefore, it is vital to better understand the public's experience with health misinformation on social media. OBJECTIVE: The goal of this analysis was to examine perceptions of the social media information environment and identify associations between health misinformation perceptions and health communication behaviors among US adults. METHODS: Analyses used data from the 2022 Health Information National Trends Survey (N=6252). Weighted unadjusted proportions described respondents' perceptions of the amount of false or misleading health information on social media ("perceived misinformation amount") and how difficult it is to discern true from false information on social media ("perceived discernment difficulty"). Weighted multivariable logistic regressions examined (1) associations of sociodemographic characteristics and subjective literacy measures with misinformation perceptions and (2) relationships between misinformation perceptions and health communication behaviors (ie, sharing personal or general health information on social media and using social media information in health decisions or in discussions with health care providers). RESULTS: Over one-third of social media users (35.61%) perceived high levels of health misinformation, and approximately two-thirds (66.56%) reported high perceived discernment difficulty. Odds of perceiving high amounts of misinformation were lower among non-Hispanic Black/African American (adjusted odds ratio [aOR] 0.407, 95% CI 0.282-0.587) and Hispanic (aOR 0.610, 95% CI 0.449-0.831) individuals compared to White individuals. Those with lower subjective health literacy were less likely to report high perceived misinformation amount (aOR 0.602, 95% CI 0.374-0.970), whereas those with lower subjective digital literacy were more likely to report high perceived misinformation amount (aOR 1.775, 95% CI 1.400-2.251). Compared to White individuals, Hispanic individuals had lower odds of reporting high discernment difficulty (aOR 0.620, 95% CI 0.462-0.831). Those with lower subjective digital literacy (aOR 1.873, 95% CI 1.478-2.374) or numeracy (aOR 1.465, 95% CI 1.047-2.049) were more likely to report high discernment difficulty. High perceived misinformation amount was associated with lower odds of sharing general health information on social media (aOR 0.742, 95% CI 0.568-0.968), using social media information to make health decisions (aOR 0.273, 95% CI 0.156-0.479), and using social media information in discussions with health care providers (aOR 0.460, 95% CI 0.323-0.655). High perceived discernment difficulty was associated with higher odds of using social media information in health decisions (aOR 1.724, 95% CI 1.208-2.460) and health care provider discussions (aOR 1.389, 95% CI 1.035-1.864). CONCLUSIONS: Perceptions of high health misinformation prevalence and discernment difficulty are widespread among social media users, and each has unique associations with sociodemographic characteristics, literacy, and health communication behaviors. These insights can help inform future health communication interventions.

Mitigating Health and Science Misinformation: A Scoping Review of Literature from 2017 to 2022.

Literature on how to address misinformation has rapidly expanded in recent years. The aim of this scoping review was to synthesize the growing published literature on health and science misinformation mitigation interventions. English-language articles published from January 2017 to July 2022 were included. After title/abstract screening, 115 publications (148 empirical studies) met inclusion criteria and were coded for sample characteristics, topics, mitigation strategies, research methods, outcomes, and intervention efficacy. A marked increase in misinformation mitigation research was observed in 2020-2022. COVID-19, vaccines, and climate change were the most frequently addressed topics. Most studies used general population samples recruited online; few focused on populations most vulnerable to misinformation. Most studies assessed cognitive outcomes (e.g., knowledge), with fewer assessing health behavior, communication behavior, or skills. Correction (k = 97) was the most used misinformation mitigation strategy, followed by education and other literacy initiatives (k = 39) and prebunking/inoculation (k = 24). Intervention efficacy varied, with 76 studies reporting positive, 17 reporting null, and 68 reporting mixed results. Most misinformation mitigation interventions were limited to short-term online experiments focused on improving cognitive outcomes. Priority research areas going forward include expanding and diversifying study samples, scaling interventions, conducting longitudinal observations, and focusing on communities susceptible to misinformation.

Understanding Associations of Personal Values With Support for Tobacco and Alcohol Control Policies.

INTRODUCTION: This cross-sectional analysis of the 2020 Health Information National Trends Survey (N=3,604) examines the associations of personal values with tobacco and alcohol control policy support, which may inform policy-related communication efforts. METHODS: Respondents selected which of 7 value options they considered most important in their daily life and rated their support for 8 proposed tobacco and alcohol control policies (1=strongly oppose, 5=strongly support). Weighted proportions for each value were described across sociodemographic characteristics, smoking status, and alcohol use. Weighted bivariate and multivariable regressions tested the associations of values with mean policy support (alpha=0.89). Analyses occurred from 2021 to 2022. RESULTS: The most frequently selected values were assuring my family is safe and secure (30.2%), being happy (21.1%), and making my own decisions (13.6%). Selected values varied across sociodemographic and behavioral characteristics. For example, people with lower education and incomes were overrepresented among those selecting making my own decisions and keeping myself in good health. After adjusting for sociodemographics, smoking, and alcohol use, people selecting family safety (ß=0.20, 95% CI=0.06, 0.33) or religious connection (ß=0.34, 95% CI=0.14, 0.54) as most important reported higher policy support than those selecting making their own decisions, the value associated with the lowest mean policy support. Mean policy support did not significantly differ across any other value comparisons. CONCLUSIONS: Personal values are associated with support for alcohol and tobacco control policies, with making my own decisions associated with the lowest policy support. Future research and communication efforts may consider aligning tobacco and alcohol control policies with the idea of supporting autonomy.

An Overview of Innovative Approaches to Support Timely and Agile Health Communication Research and Practice.

Innovative approaches are needed to make health communication research and practice more timely, responsive, and effective in a rapidly changing information ecosystem. In this paper we provide an overview of strategies that can enhance the delivery and effectiveness of health communication campaigns and interventions, as well as research approaches that can generate useful data and insights for decisionmakers and campaign designers, thereby reducing the research-to-practice gap. The discussion focuses on the following approaches: digital segmentation and microtargeting, social media influencer campaigns, recommender systems, adaptive interventions, A/B testing, efficient message testing protocols, rapid cycle iterative message testing, megastudies, and agent-based modeling. For each method highlighted, we also outline important practical and ethical considerations for utilizing the approach in the context of health communication research and practice, including issues related to transparency, privacy, equity, and potential for harm.

Missing the Bigger Picture: The Need for More Research on Visual Health Misinformation.

Research shows that health misinformation is widespread online and poses a potentially significant threat to public health. Visual misinformation has been largely overlooked, a notable gap given the unique features and ubiquity of visual content. In this essay, we (a) provide a working definition of visual misinformation, (b) summarize the main categories of visual misinformation, (c) offer examples of the functions visuals can serve within misinformation content, and (d) outline priorities for advancing research on visual misinformation. A systematic approach to studying visual misinformation can improve efforts to mitigate health misinformation and optimize science communication in the current information environment.

Making decisions about health information on social media: a mouse-tracking study.

Health misinformation is a problem on social media, and more understanding is needed about how users cognitively process it. In this study, participants' accuracy in determining whether 60 health claims were true (e.g., "Vaccines prevent disease outbreaks") or false (e.g., "Vaccines cause disease outbreaks") was assessed. The 60 claims were related to three domains of health risk behavior (i.e., smoking, alcohol and vaccines). Claims were presented as Tweets or as simple text statements. We employed mouse tracking to measure reaction times, whether processing happens in discrete stages, and response uncertainty. We also examined whether health literacy was a moderating variable. The results indicate that information in statements and tweets is evaluated incrementally most of the time, but with overrides happening on some trials. Adequate health literacy scorers were equally certain when responding to tweets and statements, but they were more accurate when responding to tweets. Inadequate scorers were more confident on statements than on tweets but equally accurate on both. These results have important implications for understanding the underlying cognition needed to combat health misinformation online.

Evidence of Youth-Appealing Cigarette Advertising Tactics from a Randomized, Controlled Experiment.

INTRODUCTION: Receptivity to tobacco advertising is an important component in the progression from exposure to advertising to use behavior, yet little is known about current tobacco advertising tactics that increase receptivity. This study tests the effect of three advertising features identified in earlier work as potentially appealing to adolescents and young adults: flora imagery, eco-friendly language, and sweepstakes. AIMS AND METHODS: We conducted an online survey in which 1,000 US adolescents (age 15-17) and 1,000 US young adults (age 18-24), equally stratified by smoking status, were exposed to three experimental modules manipulating presence/absence of each feature of interest on cigarette ads. After viewing each ad, participants reported their receptivity to the advertisement. Bivariable analysis and multivariable logistic regression analyses were used to assess the effect of each appeal's presence on receptivity. RESULTS: Adolescents (aOR = 1.55, 95%CI: 1.12-2.14) and young adults (aOR = 1.43, 95%CI: 1.06-1.93) were more likely to be receptive to ads with flora imagery. The effect of sweepstakes on receptivity was modified by the specific ad for young adults. Ecofriendly language did not significantly impact receptivity among either group. Exploratory subgroup analysis found a significant ad by sweepstakes interaction among young adult noncurrent smokers. CONCLUSION: These findings provide evidence that use of flora imagery increases cigarette advertising receptivity among adolescents and young adults, while the effect of sweepstakes on young adults might additionally depend on the ad shown. Restrictions on youth appealing advertising tactics, such as those identified in this study, as well as broader content-neutral advertising restriction policies, should be considered. IMPLICATIONS: This study provides evidence for the appeal of flora imagery in cigarette advertising for both adolescents and young adults, as well as the complexity of how use of sweepstakes interacts with branding in specific ads to predict receptivity among young adults. Because receptivity to cigarette advertising is a documented step in the pathway between advertising exposure and product use, restrictions on use of these tactics should be implemented, and broader content-neutral advertising restriction policies should be considered.

Tobacco Advertising Features That May Contribute to Product Appeal Among US Adolescents and Young Adults.

INTRODUCTION: Cigarette advertising is a causal agent of smoking uptake among young people. Although prior research links ad receptivity to tobacco product interest and use, little is known regarding the specific advertising tactics associated with increased product appeal among young people. METHODS: A national sample of 13-20 year-olds (N = 3688, youth) and 21-24 year-olds (N = 1556, young adults) in the US participated in an online survey in 2017 (mean age 18.1 years). The majority (72.0%) of youth and nearly half (44.8%) of young adults were never smokers. Participants were shown a cigarette ad, randomly assigned from a pool of 50 advertisements, and reported how much they liked the ad, and were curious about and interested in using the advertised product. All 50 advertisements were content analyzed for a variety of features. Data from the survey and content analysis were merged and mixed effects analyses used to identify the features associated with increased liking, curiosity, and interest in using, referred to collectively as product appeal. RESULTS: Presence of a sweepstakes offer was associated with increased liking, curiosity and interest among youth and curiosity and interest among young adults. Outdoors settings, flora imagery, natural descriptors, and environmental themes were associated with increased appeal. Price reductions (eg, coupons) were associated with decreased appeal among youth. CONCLUSIONS: This study identified several advertising tactics associated with increased appeal among youth and young adults. If additional research confirms these findings, the U.S. Food and Drug Association should consider restricting use of these tactics in tobacco advertising. IMPLICATIONS: This study's findings provide insight into features of cigarette ads that appeal to youth and young adults. Overall, the presence of sweepstakes appealed to youth and young adults and outdoors and environmental themes were particularly appealing to young adults. Such tactics could serve to further brand engagement, improve brand image and lead to initiation or escalation of use. If confirmatory studies further demonstrate the effects of the tactics identified in this study on youth product appeal, U.S. Food and Drug Administration should consider using its authority to restrict the use of youth-appealing tactics.

Reducing Health-Related Stigma Through Narrative Messages.

Public stigma characterizes three leading health issues: prescription opioid addiction, obesity, and cigarette smoking. Attributions of individual responsibility are often embedded in negative public attitudes around these issues and can be important to stigma's development and reduction. Research suggests that narrative messages may hold promise for influencing attributions and stigma in these health contexts. Using a national sample of American adults from an online panel (N = 5,007), we conducted a survey-embedded randomized experiment, assigning participants to read one of six messages about one of three health issues. All participants read a statement detailing the magnitude of their assigned health problem, after which some respondents received a short inoculation message (serving as a comparison group) or a narrative message emphasizing external factors while acknowledging personal responsibility for the issue. Some participants also read a counter message emphasizing personal responsibility for the health issue to replicate competitive messaging environments surrounding these issues. Relative to those who received only the magnitude of problem message (comparison group 1) or the magnitude of problem and inoculation messages (comparison group 2), the narrative message reduced prescription opioid addiction stigma and increased attributions of responsibility to groups beyond the individual. Narrative effects were mixed for obesity, had no effect on attributions or stigma around cigarette smoking, and were generally consistent whether or not respondents received a counter message. Narrative messages may be a promising approach for shifting responsibility attributions and reducing public stigma around prescription opioid addiction, and may have some relevance for obesity stigma-reduction efforts.

Sociodemographic differences in reasons for ENDS use among US youth within Wave 2 of the PATH study.

INTRODUCTION: Adolescents use electronic nicotine delivery systems (ENDS, or e-cigarettes) more than other tobacco products. Among adults, some data indicate that motivations for use vary by sociodemographic group. This study sought to examine how adolescents' motivations for ENDS use vary by sociodemographic characteristics, including age, gender, race/ethnicity and household income. METHODS: The current study used data from Wave 2 of the Population Assessment of Tobacco and Health (PATH) study. Youth who used ENDS in the past 30 days were asked to report their motivations for product use. Rates of reporting each reason for use were compared across sociodemographic groups. RESULTS: Appealing flavors was the most commonly reported motivation for using ENDS, and was mentioned more often among females (89.23%) than males (74.00%). Females were also more likely than males to report using ENDS because the product feels like smoking cigarettes (AOR=1.761) and people who are important to the participant smoke them (AOR=1.895). Older teens were more likely to report using ENDS because the product does not smell bad (56.45%, 15-17 years old; 42.83%, 12-14 years old). CONCLUSIONS: Motivations for ENDS use vary by sociodemographic group. Understanding the motivations for use among sociodemographic subgroups is an initial step towards informing the development of policies and interventions with equally distributed benefits.

Selling tobacco: A comprehensive analysis of the U.S. tobacco advertising landscape.

OBJECTIVES: To describe advertising tactics of cigarette, e-cigarette, little cigar/cigarillo and smokeless tobacco manufacturers. METHODS: We conducted a content analysis of tobacco 827 ads run in the US in 2016. Ads were double coded by trained coders across ten domains: promotions, web/social media presence, use cues, warnings and disclaimers, descriptors, claims, activities, setting, imagery, and themes. RESULTS: Cigarette ads relied on promotional tactics like discounts and sweepstakes and featured links to websites and mobile apps, all of which can increase brand loyalty and customer engagement. E-cigarette ads used tactics that appear to target new consumers, such as highlighting the product's qualities and modeling product use. Little cigar/cigarillo ads often positioned the product as social and featured music, urban and nightlife settings. Smokeless tobacco ads frequently featured themes, activities and settings stereotypically thought of as masculine. CONCLUSIONS: The tactics used to advertise tobacco products can help generate new consumers, encourage product/brand switching, and escalate use among current users. Understanding how different products are advertised can inform the Food and Drug Administration's regulatory efforts, and tobacco counter-marketing campaigns.

Gender Differences in Depression Literacy and Stigma After a Randomized Controlled Evaluation of a Universal Depression Education Program.

PURPOSE: Depression is a debilitating illness with frequent onset during adolescence. Depression affects women more often than men; men are more likely to complete suicide and less likely to seek treatment. The Adolescent Depression Awareness Program (ADAP) is a school-based depression intervention that educates adolescents about depression symptoms and addresses accompanying stigma. The study aims examined gender differences in the ADAP's impact on depression literacy and stigma. METHODS: Data came from a randomized trial (2012-2015). Six thousand six hundred seventy-nine students from 54 schools in several states were matched into pairs and randomized to the intervention or wait-list control. Teachers delivered the ADAP as part of the health curriculum. Depression literacy and stigma outcomes were measured before intervention, 6 weeks later, and at 4 months. Multilevel models evaluated whether gender moderated the effect of ADAP on depression literacy and stigma. RESULTS: At 4 months, there was a main effect of the ADAP on depression literacy (odds ratio [OR] = 3.3, p = .001) with intervention students achieving depression literacy at higher rates than controls. Gender exhibited a main effect, with women showing greater rates of depression literacy than men (OR = 1.51, p = .001). There was no significant intervention × gender interaction. The ADAP did not exhibit a significant main effect on stigma. There was a main effect for gender, with women demonstrating less stigma than men (OR = .65, p = .001). There was no significant interaction between the intervention and gender on stigma. CONCLUSIONS: The ADAP demonstrates effectiveness for increasing rates of depression literacy among high school students. In this study, gender was not associated with ADAP's effectiveness.

Ethnic and Socioeconomic Disparities in Recalled Exposure to and Self-Reported Impact of Tobacco Marketing and Promotions.

The role of tobacco marketing in tobacco use, particularly among the vulnerable ethnic and socioeconomic sub-populations is a regulatory priority of the U.S. Food and Drug Administration. There currently exist both ethnic and socioeconomic disparities in the use of tobacco products. Monitoring such inequalities in exposure to tobacco marketing is essential to inform tobacco regulatory policy that may reduce known tobacco-related health disparities. We use data from the Population Assessment of Tobacco and Health (PATH) Wave 1 youth survey to examine (1) recalled exposure to and liking of tobacco marketing for cigarettes, non-large cigars, and e-cigarettes, (2) self-reported exposure to specific tobacco marketing tactics, namely coupons, sweepstakes, and free samples, and (3) self-reported impact of tobacco marketing and promotions on product use. Findings indicate that African Americans and those of lower SES were more likely to recall having seen cigarette and non-large cigar ads. Reported exposure to coupons, sweepstakes and free samples also varied ethnically and socioeconomically. African Americans and those of lower SES were more likely than other respondents to report that marketing and promotions as played a role in their tobacco product use. Better understanding of communication inequalities and their influence on product use is needed to inform tobacco regulatory action that may reduce tobacco company efforts to target vulnerable groups. Tobacco education communication campaigns focusing on disproportionately affected groups could help counter the effects of targeted industry marketing.

School-Based Curriculum to Improve Depression Literacy Among US Secondary School Students: A Randomized Effectiveness Trial.

OBJECTIVES: To determine the effectiveness of a universal school-based depression education program. METHODS: In 2012-2015, we matched 6679 students from 66 secondary schools into pairs by state (Maryland, Delaware, Pennsylvania, Michigan, and Oklahoma) and randomized to the Adolescent Depression Awareness Program (ADAP; n = 3681) or to a waitlist control condition (n = 2998). Trained teachers delivered ADAP as part of the health education curriculum to students aged 14 to 15 years. The primary outcome was depression literacy. Secondary outcomes included mental health stigma and, in a subset of the sample, the receipt of mental health services. Follow-up was at 4 months. RESULTS: ADAP resulted in significantly higher levels of depression literacy among participating students than did waitlist controls, after adjusting for pretest assessment depression literacy (P < .001). Overall, ADAP did not significantly affect stigma (P = .1). After ADAP, students approached 46% of teachers with concerns about themselves or others. Of students who reported the need for depression treatment, 44% received treatment within 4 months of ADAP implementation. CONCLUSIONS: ADAP is an effective public health intervention for improving depression literacy among students. TRIAL REGISTRATION: Clinicaltrials.gov NCT02099305.

Public perceptions of arguments supporting and opposing recreational marijuana legalization.

In debates about recreational marijuana legalization, pro-legalization arguments highlighting economic and other potential policy benefits compete with anti-legalization arguments emphasizing public health risks. In 2016, we conducted a national survey using an online panel (N=979) designed to answer two main research questions: (1) How do Americans perceive the relative strength of competing arguments about recreational marijuana legalization? (2) How are perceptions of argument strength associated with public support for recreational marijuana legalization? We examined differences in attitudes among individuals living in states that have/have not legalized recreational marijuana and among Democrats/Independents/Republicans. Ordered logit regression assessed the relationship between perceived argument strength and public support for recreational marijuana legalization. Respondents rated pro-legalization arguments highlighting beneficial economic and criminal justice consequences as more persuasive than anti-legalization arguments emphasizing adverse public health effects. Respondents were more likely to agree with arguments highlighting legalization's potential to increase tax revenue (63.9%) and reduce prison overcrowding (62.8%) than arguments emphasizing negative consequences on motor vehicle crashes (51.8%) and youth health (49.6%). The highest rated anti-legalization arguments highlighted the conflict between state and federal marijuana laws (63.0%) and asserted that legalization will fail to eliminate the black market (57.2%). Respondents who endorsed pro-legalization economic and criminal justice arguments were more likely than other respondents to support legalization. Our findings indicate that, on both side of the recreational marijuana legalization debate, there are arguments that resonate with the American public. However, public health risk messages were viewed as less compelling than pro-legalization economic and criminal justice-oriented arguments.