Adapting a Financial Incentives Intervention for Smoking Cessation with Alaska Native Families: Phase 1 Qualitative Research to Inform the Aniqsaaq (To Breathe) Study.

INTRODUCTION: Alaska Native and American Indian (ANAI) peoples in Alaska currently experience a disproportionate burden of morbidity and mortality from tobacco cigarette use. Financial incentives for smoking cessation are evidence-based, but a family-level incentive structure has not been evaluated. We used a community-based participatory research and qualitative approach to culturally adapt a smoking cessation intervention with ANAI families. METHODS: We conducted individual, semi-structured telephone interviews with 12 ANAI adults who smoke, 12 adult family members, and 13 Alaska Tribal Health System stakeholders statewide between November 2022-March 2023. Through content analysis, we explored intervention receptivity, incentive preferences, culturally aligned recruitment and intervention messaging, and future implementation needs. RESULTS: Participants were receptive to the intervention. Involving a family member was viewed as novel and aligned with ANAI cultural values of commitment to community and familial interdependence. Major themes included choosing a family member who is supportive and understanding, keeping materials positive and encouraging, and offering cash and non-cash incentives for family members to choose (e.g., fuel, groceries, activities). Participants indicated that messaging should emphasize family collaboration and that cessation resources and support tips should be provided. Stakeholders also reinforced that program materials should encourage the use of other existing evidence-based cessation therapies (e.g., nicotine replacement, counseling). CONCLUSIONS: Adaptations, grounded in ANAI cultural strengths were made to the intervention and recruitment materials based on participant feedback. Next steps include a beta-test for feasibility and a randomized controlled trial for efficacy. IMPLICATIONS: This is the first study to design and adapt a financial incentives intervention promoting smoking cessation among Alaska Native or American Indian (ANAI) peoples and the first to involve the family system. Feedback from this formative work was used to develop a meaningful family-level incentive structure with ANAI people who smoke and family members and ensure intervention messaging is supportive and culturally aligned. The results provide qualitative knowledge that can inform future family-based interventions with ANAI communities, including our planned randomized controlled trial of the intervention.

Smoking Cessation, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology.

Although the harmful effects of smoking after a cancer diagnosis have been clearly demonstrated, many patients continue to smoke cigarettes during treatment and beyond. The NCCN Guidelines for Smoking Cessation emphasize the importance of smoking cessation in all patients with cancer and seek to establish evidence-based recommendations tailored to the unique needs and concerns of patients with cancer. The recommendations contained herein describe interventions for cessation of all combustible tobacco products (eg, cigarettes, cigars, hookah), including smokeless tobacco products. However, recommendations are based on studies of cigarette smoking. The NCCN Smoking Cessation Panel recommends that treatment plans for all patients with cancer who smoke include the following 3 tenets that should be done concurrently: (1) evidence-based motivational strategies and behavior therapy (counseling), which can be brief; (2) evidence-based pharmacotherapy; and (3) close follow-up with retreatment as needed.

Current tobacco smoking and risk of SARS-CoV-2 infection and hospitalization: Evaluating the role of socio-demographic factors and comorbidities.

Our recently published study of >2.4 million adults in Northern California indicated that current versus never-tobacco smoking was associated with lower risk of SARS-CoV-2 infection and less severe coronavirus disease 2019 (COVID-19). We extended this research by evaluating whether these associations were moderated by socio-demographic factors and medical comorbidities. This retrospective cohort study of 1,885,826 adults with current or never-smoking status in Kaiser Permanente Northern California from 3/5/2020 (baseline) to 12/31/2020 (pre-vaccine) included electronic health record-based socio-demographics (sex, age, race/ethnicity, neighborhood deprivation index (NDI)) and medical comorbidities (obesity, cardiovascular conditions, diabetes, renal disease, respiratory conditions). We estimated the adjusted risk of SARS-CoV-2 infection and hospitalization (≤30 days of infection) associated with smoking status using Cox proportional hazard regression models. We estimated associations within subgroups of socio-demographics and comorbidities, and tested for effect modification using interaction terms. During the study, 35,627 patients had SARS-CoV-2 infection. Current versus never-smoking status was associated with lower adjusted rates of SARS-CoV-2 infection (aHR ranging from 0.51 to 0.89) and hospitalization (aHR ranging from 0.32 to 0.70) within nearly every socio-demographic and comorbidity subgroup. Statistically significant interactions showed that the magnitude of protection for SARS-CoV-2 infection varied by sex, age, race/ethnicity, NDI, cardiovascular conditions and diabetes, and for SARS-CoV-2 hospitalization by age and renal disease. Taken together, results indicated that while some socio-demographics and comorbidities moderated the associations, the lower risk of SARS-CoV-2 infection and hospitalization associated with current versus never-smoking status persisted among patients regardless of socio-demographics or comorbidities.

Tobacco Smoking and Risk of SARS-CoV-2 Infection and Disease Severity Among Adults in an Integrated Healthcare System in California.

INTRODUCTION: The relationship between tobacco smoking status and SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) severity is highly debated. We conducted a retrospective cohort study of >2.4 million adults in a large healthcare system to evaluate whether smoking is associated with SARS-CoV-2 infection and disease severity. AIMS AND METHODS: This retrospective cohort study of 2,427,293 adults in KPNC from March 5, 2020 (baseline) to December 31, 2020 (pre-vaccine) included smoking status (current, former, never), socio-demographics, and comorbidities from the electronic health record. SARS-CoV-2 infection (identified by a positive PCR test) and COVID-19 severity (hospitalization, ICU admission or death ≤ 30 days of COVID-19 diagnosis) were estimated in time-to-event analyses using Cox proportional hazard regression models adjusting for covariates. Secondary analyses examined COVID-19 severity among patients with COVID-19 using logistic regression. RESULTS: During the study, 44,270 patients had SARS-CoV-2 infection. Current smoking was associated with lower adjusted rates of SARS-CoV-2 infection (aHR = 0.64 95% CI: 0.61-0.67), COVID-19-related hospitalization (aHR = 0.48 95% CI: 0.40-0.58), ICU admission (aHR = 0.62 95% CI: 0.42-0.87), and death (aHR = 0.52 95% CI: 0.27-0.89) than never-smoking. Former smoking was associated with a lower adjusted rate of SARS-CoV-2 infection (aHR = 0.96 95% CI: 0.94-0.99) and higher adjusted rates of hospitalization (aHR = 1.10 95% CI: 1.03-1.08) and death (aHR = 1.32 95% CI: 1.11-1.56) than never-smoking. Logistic regression analyses among patients with COVID-19 found lower odds of hospitalization for current versus never-smoking and higher odds of hospitalization and death for former versus never-smoking. CONCLUSIONS: In the largest US study to date on smoking and COVID-19, current and former smoking showed lower risk of SARS-CoV-2 infection than never-smoking, while a history of smoking was associated with higher risk of severe COVID-19. IMPLICATIONS: In this cohort study of 2.4 million adults, adjusting for socio-demographics and medical comorbidities, current tobacco smoking was associated with a lower risk of both SARS-CoV-2 infection and severe COVID-19 illness compared to never-smoking. A history of smoking was associated with a slightly lower risk of SARS-CoV-2 infection and a modestly higher risk of severe COVID-19 illness compared to never-smoking. The lower observed COVID-19 risk for current versus never-smoking deserves further investigation. Results support prioritizing individuals with smoking-related comorbidities for vaccine outreach and treatments as they become available.

Facebook Intervention to Connect Alaska Native People With Resources and Support to Quit Smoking: CAN Quit Pilot Randomized Controlled Trial.

INTRODUCTION: There is some evidence that social media interventions can promote smoking cessation. This randomized controlled pilot study is the first to evaluate the feasibility and potential efficacy of a Facebook smoking cessation intervention among Alaska Native (AN) adults. AIMS AND METHODS: Recruitment and data collection occurred from December 2019 to March 2021. Participants were recruited statewide in Alaska using Facebook advertisements with a targeted sample of 60 enrolled. Participants were stratified by gender, age, and rural or urban residence and randomly assigned to receive referral resources on evidence-based cessation treatments (EBCTs) (control, n = 30) or these resources plus a 3-month, closed (private), culturally tailored, Facebook group (intervention, n = 31) that connected participants to EBCT resources and was moderated by two Alaska Native Trained Tobacco Specialists. Assessments were conducted online post-randomization at 1, 3, and 6 months. Outcomes were feasibility (recruitment, retention, and intervention engagement), self-reported use of EBCTs, and biochemically confirmed seven-day point-prevalence smoking abstinence. RESULTS: Of intervention participants, 90% engaged (eg posted, commented) more than once. Study retention was 57% at 6 months (no group differences). The proportion utilizing EBCTs was about double for intervention compared with the control group participants at 3 and 6 months. Smoking abstinence was higher for intervention than control participants at 3 months (6.5% vs. 0%, p = .16) but comparable at 6 months (6.4% vs. 6.7%, p = .97). CONCLUSIONS: While additional research is needed to promote long-term cessation, this pilot trial supports recruitment feasibility during the Coronavirus Disease 2019 (COVID-19) pandemic, consumer uptake, and a signal for intervention efficacy on the uptake of cessation treatment and short-term smoking abstinence. IMPLICATIONS: This study is the first evaluation of a social media intervention for smoking cessation among Indigenous people. We learned that statewide Facebook recruitment of AN adults who smoke was feasible and there was a signal for the efficacy of a Facebook intervention on the uptake of EBCT and short-term (3 months) biochemically verified smoking abstinence. Clinically, social media platforms may complement current care models by connecting AN individuals and others living in hard-to-reach communities to cessation treatment resources.

Native owned and grown or demeaning and offensive? American Indian adults' perspectives on Natural American Spirit branded cigarettes.

INTRODUCTION: Owned by a major US tobacco company with no American Indian/Alaska Native (AI/AN) tribal affiliation, Natural American Spirit (NAS) cigarette packs feature an American Indian warrior, thunderbird and peace pipe. The current study examined AI/AN adults' perceptions of NAS cigarette packs in the US, which have not been reported on prior. METHODS: AI/AN adults were recruited via Qualtrics national panels (n=500; 64% female, age M=39.9 years, 47% current smokers) in 2020. After viewing NAS pack images online (front, back and sides), participants were asked about NAS tribal affiliation, health perceptions and purchase intentions. Participants also wrote-in what the NAS pack logos meant to them. RESULTS: Most participants (65%) believed NAS is AI/AN-owned and/or grown on tribal lands. Among current smokers, beliefs of an AI/AN affiliation were associated with misperceptions of NAS being a healthier cigarette and with greater intention to purchase NAS cigarettes (p's<0.01). Participants who did not believe NAS was grown or owned by AI/AN tribes were more likely to describe the NAS warrior logo as cultural misappropriation (17%) than participants who believed NAS was AI/AN tribally affiliated (4%, p<0.001). CONCLUSIONS: The findings indicate a dichotomy in beliefs among surveyed AI/AN adults regarding NAS brand cigarettes. A majority held the misconception that NAS is tribally affiliated, while an informed and concerned minority characterised the branding as cultural misappropriation. The current packaging is reasonably expected to result in beliefs that NAS cigarettes are AI/AN tribally affiliated, and these beliefs may be associated with misperceptions of lesser harm.

Rapid-response surveillance of the first US test market for VLN cigarettes.

INTRODUCTION: VLN King menthol and non-menthol are the first combustible cigarettes to receive US Food and Drug Administration (FDA) authorisation as modified risk tobacco products. Focusing on the first retail test market, this study characterised VLN advertising, product placement, discounts and price. METHODS: All Chicago-area Circle K stores (n=133) were telephoned to assess whether they sold VLN. Single-pack price of non-menthol was obtained in 57 of 100 stores that sold VLN. In fall 2022, trained data collectors visited those 57 stores to assess VLN product placement, advertising, discounts and prices. Paired t-tests compared observed VLN price with telephone price and to price of other cigarette brands. RESULTS: Nearly all stores (91.1%) displayed exterior advertisements for VLN, and 41.1% displayed interior advertising, with 8.9% of stores advertising VLN in the power wall but never in the header row. VLN cigarettes were displayed in the power wall exclusively and among high-nicotine cigarettes. Some VLN marketing claims were not FDA-authorised. VLN advertised a sweepstakes offer and rewards programme. Most stores (85.7%) offered VLN discounts. VLN was priced like a premium brand (mean=$10.90, SD=$1.53), and prices obtained by telephone did not differ from observed prices several months later. CONCLUSIONS: Retail marketing strategies for VLN mimic those for high-nicotine cigarettes. Deviations from FDA-authorised marketing claims were evident. Surveillance in future test markets is recommended to assess compliance with marketing claims and examine relative price and discount offers. Of interest is how premium-priced, low-nicotine cigarettes stand to compete in a market dominated by cheaper high-nicotine cigarettes.

Cytisinicline for Smoking Cessation: A Randomized Clinical Trial.

Importance: Cytisinicline (cytisine) is a plant-based alkaloid that, like varenicline, binds selectively to α4ß2 nicotinic acetylcholine receptors, which mediate nicotine dependence. Although not licensed in the US, cytisinicline is used in some European countries to aid smoking cessation, but its traditional dosing regimen and treatment duration may not be optimal. Objective: To evaluate the efficacy and tolerability of cytisinicline for smoking cessation when administered in a novel pharmacokinetically based dosing regimen for 6 or 12 weeks vs placebo. Design, Setting, and Participants: A 3-group, double-blind, placebo-controlled, randomized trial (ORCA-2) compared 2 durations of cytisinicline treatment (6 or 12 weeks) vs placebo, with follow-up to 24 weeks, among 810 adults who smoked cigarettes daily and wanted to quit. It was conducted at 17 US sites from October 2020 to December 2021. Interventions: Participants were randomized (1:1:1) to cytisinicline, 3 mg, 3 times daily for 12 weeks (n = 270); cytisinicline, 3 mg, 3 times daily for 6 weeks then placebo 3 times daily for 6 weeks (n = 269); or placebo 3 times daily for 12 weeks (n = 271). All participants received behavioral support. Main Outcomes and Measures: Biochemically verified continuous smoking abstinence for the last 4 weeks of cytisinicline treatment vs placebo (primary) and from end of treatment to 24 weeks (secondary). Results: Of 810 randomized participants (mean age, 52.5 years; 54.6% female; mean of 19.4 cigarettes smoked daily), 618 (76.3%) completed the trial. For the 6-week course of cytisinicline vs placebo, continuous abstinence rates were 25.3% vs 4.4% during weeks 3 to 6 (odds ratio [OR], 8.0 [95% CI, 3.9-16.3]; P < .001) and 8.9% vs 2.6% during weeks 3 to 24 (OR, 3.7 [95% CI, 1.5-10.2]; P = .002). For the 12-week course of cytisinicline vs placebo, continuous abstinence rates were 32.6% vs 7.0% for weeks 9 to 12 (OR, 6.3 [95% CI, 3.7-11.6]; P < .001) and 21.1% vs 4.8% during weeks 9 to 24 (OR, 5.3 [95% CI, 2.8-11.1]; P < .001). Nausea, abnormal dreams, and insomnia occurred in less than 10% of each group. Sixteen participants (2.9%) discontinued cytisinicline due to an adverse event. No drug-related serious adverse events occurred. Conclusions and Relevance: Both 6- and 12-week cytisinicline schedules, with behavioral support, demonstrated smoking cessation efficacy and excellent tolerability, offering new nicotine dependence treatment options. Trial Registration: ClinicalTrials.gov Identifier: NCT04576949.

Electronic cigarette use and risk of COVID-19 among young adults without a history of cigarette smoking.

It is unknown whether use of e-cigarettes increases susceptibility to COVID-19. In a large clinical sample of young adults, we evaluated whether current or ever e-cigarette use was associated with polymerase chain reaction (PCR)-confirmed COVID-19. To address the confounding of combustible smoking, the sample was restricted to never smokers. This retrospective cohort study analyzed data from the electronic health records of 74,853 young adults (aged 18-35 years), without a history of cigarette smoking, who were screened for e-cigarette use (current, former, never) in the Kaiser Permanente Northern California (KPNC) healthcare system from 3/5/2020 (baseline) to 11/30/2020 (pre-vaccine). COVID-19 risk was estimated in time-to-event analyses using multivariable Cox proportional hazard regression models, adjusted for socio-demographics and medical comorbidities. E-cigarette status in the cohort was: 1.6% current, 1.2% former, and 97.2% never. During follow-up, 1965 (2.6%) patients acquired COVID-19. We did not find evidence that current (vs never) e-cigarette use was associated with risk of COVID-19 (aHR = 1.12 95%CI:0.77-1.62). However, we did find suggestive evidence that former (versus never) e-cigarette use may be associated with greater risk of COVID-19 (aHR = 1.39 95%CI:0.98-1.96). While e-cigarette use is associated with health risks for young adults, results from this study suggest that current use of e-cigarettes may not increase susceptibility for COVID-19 among young adults who have never smoked cigarettes.

Nicotine delivery and cigarette equivalents from vaping a JUULpod.

With patented nicotine salt technology, JUUL dominates the e-cigarette market. We reviewed studies of JUUL's nicotine pharmacokinetic profile and studies quantifying nicotine in a JUULpod, emitted in the aerosol and absorbed by users. Examined in eight studies, JUUL's peak nicotine levels were half to three-quarters that of a combustible cigarette in industry-conducted studies with JUUL-naïve users, while comparable to or greater than combustible cigarettes in independent studies of experienced e-cigarette users. JUUL Labs reports each 5% (nicotine-by-weight) cartridge contains approximately 40 mg nicotine per pod and is 'approximately equivalent to about 1 pack of cigarettes.' In five independent studies, nicotine in the liquid in a JUULpod ranged from 39.3 to 48.3 mg. Seven studies measured nicotine delivery via vaping-machine generated aerosols, varying in puffing regimes and equipment. One study estimated 68% transfer efficiency to the aerosol, measuring 28.8 mg nicotine per JUULpod. The other studies reported nicotine values ranging from 72 to 164 µg/puff. At 200 puffs, this is 14.4-32.8 mg of nicotine per pod with equivalence to 13-30 cigarettes. A study measuring nicotine levels in JUUL users during a 5-day controlled switch found equivalence to 18 cigarettes. One JUULpod appears capable of delivering the nicotine equivalent to smoking about a pack of cigarettes, with variability. In JUUL-naïve smokers, JUUL's nicotine boost was lower than that of combustible cigarettes; while in experienced users, JUUL was comparable. Minimising harshness and adaptive to user experience, JUUL's design facilitates initiation to a high nicotine, and ultimately, highly addictive vaping product.

Lessons Learned From Beta-Testing a Facebook Group Prototype to Promote Treatment Use in the "Connecting Alaska Native People to Quit Smoking" (CAN Quit) Study.

Social media provides an effective tool to reach, engage, and connect smokers in cessation efforts. Our team developed a Facebook group, CAN Quit (Connecting Alaska Native People to Quit smoking), to promote use of evidence-based smoking cessation resources for Alaska Native people living in Alaska, which are underused despite their effectiveness. Often separated by geography and climate, Alaska Native people prefer group-based approaches for tobacco cessation that support their culture and values. Such preferences make Alaska Native people candidates for social media-based interventions that promote connection. This viewpoint discusses the steps involved and lessons learned in building and beta-testing our Facebook group prototype, which will then be evaluated in a pilot randomized controlled trial. We describe the process of training moderators to facilitate group engagement and foster community, and we describe how we developed and tested our intervention prototype and Facebook group. All parts of the prototype were designed to facilitate use of evidence-based cessation treatments. We include recommendations for best practices with the hope that lessons learned from the CAN Quit prototype could provide a model for others to create similar platforms that benefit Alaska Native and American Indian people in the context of smoking cessation.

Buddies as In-Group Influencers in Online Support Groups: A Social Network Analysis of Processes and Outcomes.

Buddies, serving as in-group influencers to aid demographically similar cobuddies, are extensively used in face-to-face support groups to enhance positive social influence. The authors examine the efficacy of buddies in online support groups and investigate underlying mediating processes using social network analysis. They observe what happens when members of support groups for quitting smoking, including members who are relatively active and less active in the group, after a few days are called on to be buddies and assigned to specific cobuddies. The findings indicate that, consistent with normative expectations for buddies, members form especially strong ties with their designated cobuddies. The more active buddies are in the group, the stronger the ties they form with their cobuddies and, in turn, their cobuddies form stronger ties with group members overall, which then relates to cobuddy goal attainment. The findings suggest that interactive marketers should consider using buddies in online support groups but observe activity levels before making buddy assignments, because positive outcomes are contingent on buddies being active in the group. Marketers should also ensure that online support group members post to everyone, not just their buddies, because ties formed among group members as a whole are crucial for goal attainment.

Is it "loud" enough?: A qualitative investigation of blunt use among African American young adults.

Heavy blunt use is common among young adult cannabis users, especially African Americans. This exploratory qualitative study aimed to examine how African American young adults understand, talk about and experience their blunt use. Semi-structured interviews were conducted with adults reporting daily or almost daily blunt use in the past month (N = 20; 75% male). Thematic analysis of the audio-recorded interviews revealed aspects of how blunts are described, made and used among heavy blunt users. The three emergent themes have implications for the assessment of cannabis use and intervention development for heavy blunt users.

Tobacco product use and susceptibility to use among sexual minority and heterosexual adolescents.

Sexual identity is associated with tobacco use in adults. We examined tobacco use and susceptibility to use by sexual identity in adolescents. Data were collected in February 2019 via Qualtrics research participant panels. Data analyses were performed in June 2019 and updated in October 2020. Respondents aged 13-17 reported sexual identity (heterosexual vs. sexual minority [lesbian, gay, bisexual, or other]), past-month and lifetime tobacco product use, susceptibility to e-cigarette use, friend(s)' e-cigarette use, tobacco marketing exposure, and demographic characteristics. The sample (n=983) was 72.9% female, 46.5% non-Hispanic white, and 26.1% sexual minority with a mean age of 15.0 years (SD=1.4). Sexual minority adolescents were more likely to have friend(s) who vape (53.0% versus 42.0%; p=0.003). In adjusted models, sexual minority adolescents had greater odds of ever smoking tobacco (odds ratio [OR]=2.06; 95% confidence interval [CI]: 1.42-2.98) or using e-cigarettes (OR=1.55; 95% CI: 1.08-2.25) relative to heterosexual adolescents. Past-month tobacco smoking and e-cigarette use did not differ by sexual identity. Among participants who had never used tobacco products, sexual minority adolescents reported greater susceptibility to e-cigarette use (OR=1.62; 95% CI: 1.04-2.52) compared to heterosexual adolescents. Exposure to cigarette and e-cigarette marketing, e-cigarette use by friends, and respondent sex were significant covariates in all models. The current findings indicate greater susceptibility to use e-cigarettes and greater tobacco product initiation, but not continuation, among sexual minority adolescents. Sexual minority-tailored interventions may be warranted to prevent tobacco product initiation. Worth exploring are the associations between sexual identity, tobacco marketing exposure, and friend(s)' e-cigarette use.

Tobacco Product Promotions Remain Ubiquitous and Are Associated with Use and Susceptibility to Use Among Adolescents.

INTRODUCTION: The decline in tobacco smoking among US adolescents has been exceeded by the exponential rise in nicotine vaping with an overall net gain in youth tobacco product use. While cigarette companies are restricted from advertising on television/radio, vaping promotions have been largely unrestricted. This study examined exposure to tobacco product promotions in a US sample of 1003 adolescents and its associations with product use and susceptibility to use. AIMS AND METHODS: Adolescents (13-17) were recruited online and anonymously surveyed in 2019 about their ever and current (past 30 days) tobacco smoking (cigarette and cigar) and nicotine vaping behaviors, and among never-users, susceptibility to vaping. Multivariate models tested associations with past-month exposure to tobacco product promotions controlling for demographic features, harm perceptions, and family and peer influences. RESULTS: Tobacco product use was 34% ever-use and 20% current-use. Most had seen cigarette (91%) and nicotine vaping (80%) product promotions in the past 30 days. A majority reported exposure at point-of-sale and on major (television and cinema) and social media. In adjusted multivariate models, greater exposure to tobacco product promotions was significantly associated with ever and current smoking and vaping; and among never-users, susceptibility to vaping (all p < .01, effect sizes 1.03-1.05). Family/peer use and attitudes also were significant correlates. CONCLUSIONS: Tobacco product promotions remain ubiquitous and are significantly associated with adolescents' tobacco product use and susceptibility to vape. Peers and family are important social influences and may reflect indirect channels of tobacco marketing. Stricter regulatory restrictions on tobacco marketing to young people are warranted. IMPLICATIONS: This study adds to mounting evidence showing that tobacco marketing remains pervasive and is associated with tobacco use and susceptibility to use. Most youth report seeing cigarette and nicotine vaping product promotions, with notable differences by channel: traditional media predominate for cigarettes and social media/email for e-cigarettes. Greater exposure to tobacco promotions is significantly associated with ever and current smoking and vaping, and among never-users, susceptibility to vaping. The accumulating findings support stricter regulatory restrictions on marketing of tobacco products in media channels accessed by youth.

Effects of Social Media on Adolescents' Willingness and Intention to Use E-Cigarettes: An Experimental Investigation.

INTRODUCTION: This study examined the effects of experimentally manipulated social media exposure on adolescents' willingness and intention to use e-cigarettes. AIMS AND METHODS: Participants were 135 adolescents of age 13-18 (52.6% female, mean age = 15.3) in California. Participants viewed six social media posts online in a 2 (post source: peer or advertisement) × 2 (e-cigarette content exposure: heavy or light) between-subjects design. Analyses were weighted to population benchmarks. We examined adolescents' beliefs, willingness, and intention to use e-cigarettes in association with social media use intensity in daily life and with experimentally manipulated exposure to social media posts that varied by source (peer or advertisement) and content (e-cigarette heavy or light). RESULTS: Greater social media use in daily life was associated with greater willingness and intention to use e-cigarettes and more positive attitudes, greater perceived norms, and lower perceived danger of e-cigarette use (all p-values <.01). In tests of the experimental exposures, heavy (vs. light) e-cigarette content resulted in greater intention (p = .049) to use e-cigarettes and more positive attitudes (p = .019). Viewing advertisements (vs. peer-generated posts) resulted in greater willingness and intention (p-values <.01) to use e-cigarettes, more positive attitudes (p = .003), and greater norm perceptions (p = .009). The interaction effect of post source by post content was not significant for any of the outcomes (all p-values >.529). CONCLUSIONS: Greater social media use and heavier exposure to advertisements and e-cigarette content in social media posts are associated with a greater risk for e-cigarette use among adolescents. Regulatory action is needed to prohibit sponsored e-cigarette content on social media platforms used by youth. IMPLICATIONS: Adolescents who use social media intensely may be at higher risk for e-cigarette use. Even brief exposure to e-cigarette content on social media was associated with greater intention to use and more positive attitudes toward e-cigarettes. Regulatory action should be taken to prohibit sponsored e-cigarette content on social media used by young people, including posts by influencers who appeal to young people.

Developing a Social Media Intervention to Connect Alaska Native People Who Smoke with Resources and Support to Quit Smoking: The Connecting Alaska Native Quit Study.

BACKGROUND: Face-to-face tobacco cessation has had limited reach and efficacy in Alaska Native (AN) communities. We describe our two-phased approach to develop content for Connecting Alaska Native People to Quit Smoking, a Facebook group intervention to reduce barriers to evidence-based smoking cessation treatment for AN people in Alaska. METHODS: Phase 1 included semi-structured telephone interviews with 30 AN people who smoke and ten stakeholders. They provided feedback on existing content from the Centers for Disease Control and Prevention Tips campaign and AN digital stories. Phase 2 included an online survey with a new group of 40 AN smokers who provided feedback on existing content via a measure of perceived effectiveness and cultural relevance. RESULTS: Phase I results revealed participants evaluated content based upon story strength, relevance to AN culture, emotional appeal, relatability to AN people, and favorite video. No single posting was rated highly across all themes. All perceived effectiveness (PE) and cultural relevance median scores fell between 3.5 and 4.4 (range 1-5). PE scores varied across participant demographic groups. CONCLUSIONS: Content embodying characteristics perceived to be most appealing, effective, and culturally relevant were selected for the private Facebook group content library with refinements made to incorporate images of AN people engaged in AN activities. PE scores indicate a need for a wide variety of content that moderators could pull from when conducting the intervention. IMPLICATIONS: Social media content targeting specific population sectors, such as American Indian/AN people for tobacco cessation needs to be culturally tailored. Our approach provides a model others can follow to determine what is appealing, relevant, and effective messaging. CLINICAL TRIAL REGISTRATION: NCT03645941.

A Therapeutic Relational Agent for Reducing Problematic Substance Use (Woebot): Development and Usability Study.

BACKGROUND: Misuse of substances is common, can be serious and costly to society, and often goes untreated due to barriers to accessing care. Woebot is a mental health digital solution informed by cognitive behavioral therapy and built upon an artificial intelligence-driven platform to deliver tailored content to users. In a previous 2-week randomized controlled trial, Woebot alleviated depressive symptoms. OBJECTIVE: This study aims to adapt Woebot for the treatment of substance use disorders (W-SUDs) and examine its feasibility, acceptability, and preliminary efficacy. METHODS: American adults (aged 18-65 years) who screened positive for substance misuse without major health contraindications were recruited from online sources and flyers and enrolled between March 27 and May 6, 2020. In a single-group pre/postdesign, all participants received W-SUDs for 8 weeks. W-SUDs provided mood, craving, and pain tracking and modules (psychoeducational lessons and psychotherapeutic tools) using elements of dialectical behavior therapy and motivational interviewing. Paired samples t tests and McNemar nonparametric tests were used to examine within-subject changes from pre- to posttreatment on measures of substance use, confidence, cravings, mood, and pain. RESULTS: The sample (N=101) had a mean age of 36.8 years (SD 10.0), and 75.2% (76/101) of the participants were female, 78.2% (79/101) were non-Hispanic White, and 72.3% (73/101) were employed. Participants' W-SUDs use averaged 15.7 (SD 14.2) days, 12.1 (SD 8.3) modules, and 600.7 (SD 556.5) sent messages. About 94% (562/598) of all completed psychoeducational lessons were rated positively. From treatment start to end, in-app craving ratings were reduced by half (87/101, 86.1% reporting cravings in the app; odds ratio 0.48, 95% CI 0.32-0.73). Posttreatment assessment completion was 50.5% (51/101), with better retention among those who initially screened higher on substance misuse. From pre- to posttreatment, confidence to resist urges to use substances significantly increased (mean score change +16.9, SD 21.4; P<.001), whereas past month substance use occasions (mean change -9.3, SD 14.1; P<.001) and scores on the Alcohol Use Disorders Identification Test-Concise (mean change -1.3, SD 2.6; P<.001), 10-item Drug Abuse Screening Test (mean change -1.2, SD 2.0; P<.001), Patient Health Questionnaire-8 item (mean change 2.1, SD 5.2; P=.005), Generalized Anxiety Disorder-7 (mean change -2.3, SD 4.7; P=.001), and cravings scale (68.6% vs 47.1% moderate to extreme; P=.01) significantly decreased. Most participants would recommend W-SUDs to a friend (39/51, 76%) and reported receiving the service they desired (41/51, 80%). Fewer felt W-SUDs met most or all of their needs (22/51, 43%). CONCLUSIONS: W-SUDs was feasible to deliver, engaging, and acceptable and was associated with significant improvements in substance use, confidence, cravings, depression, and anxiety. Study attrition was high. Future research will evaluate W-SUDs in a randomized controlled trial with a more diverse sample and with the use of greater study retention strategies. TRIAL REGISTRATION: ClinicalTrials.gov NCT04096001; http://clinicaltrials.gov/ct2/show/NCT04096001.

E-Cigarettes: Harmful or Harm-Reducing? Evaluation of a Novel Online CME Program for Health Care Providers.

AIM: Patients are asking health care providers about e-cigarettes, vaping, and other electronic nicotine delivery systems (ENDS). Provider advice on ENDS has varied greatly, suggesting a need for evidence-based continuing medical education (CME). SETTING: A novel free online CME course was developed on ENDS risks and benefits, product types (e.g., vape pens, pods), and screening and counseling best practices for adults, adolescents, and different smoker profiles (e.g., daily, social). PARTICIPANTS: From January 2017 through June 2018, 1061 individuals accessed the course: 46% physicians, 7% physician assistants, 7% nurse practitioners, 15% nurses, 4% pharmacists, and 28% allied health/student/other; 41% were international. PROGRAM DESCRIPTION: The course was built from observed online patient-provider interactions. Through video role-plays, expert interviews, and interactive activities, the course engaged learners in the evidence on ENDS. Completers earned 1.5 CME units. PROGRAM EVALUATION: A total of 555 health care providers earned 832.5 CME units. Pre- to post-test scores significantly increased from 57 to 90%; 76% rated the course as above average (41%) or outstanding (35%); 99% indicated the course was free of commercial bias. DISCUSSION: Addressing the growing need for balanced provider education on ENDS, this interactive online CME engaged learners and increased knowledge on devices and evidence-based cessation approaches.

Multiple Health Risk Behaviors in Young Adult Smokers: Stages of Change and Stability over Time.

BACKGROUND: Health risk behaviors (HRBs) are common, yet not well understood in young adult smokers. PURPOSE: We examined HRB profiles over 12 months in young adult smokers participating in a Facebook smoking cessation intervention clinical trial. METHODS: Participants (N = 500; age M = 20.9 years; 54.6% women) were recruited online and randomized to receive either a 3-month Facebook smoking cessation intervention or referral to Smokefree.gov (control). A Health Risk Assessment determined risk for 10 behaviors at baseline and 3, 6, and 12 months. Latent class analysis (LCA) and latent transition analysis (LTA) were used to identify patterns of HRBs and changes over time. RESULTS: At baseline, participants reported an average of 5.4 (standard deviation [SD] = 1.7) risk behaviors, including smoking (100%), high-fat diet (84.8%), poor sleep hygiene (71.6%), and low fruit and vegetable intake (69.4%). A 3-class model fit the data best at baseline and all follow-up time points: low risk (28.8% at baseline) with low likelihood of risk on all behaviors except smoking, substance use risk (14.0% at baseline) characterized by heavy episodic drinking, cannabis use, and other illicit drug use, and metabolic risk (57.2% at baseline), with a high percentage of members at risk for a low fruit and vegetable intake, high-fat diet, inactivity, stress, and poor sleep hygiene. Classes were very stable at 3, 6, and 12 months, with few participants transitioning between classes. CONCLUSIONS: Most young adult smokers engaged in multiple risk behaviors, with meaningful clustering of behaviors, and demonstrated stability over a year's time. In addition to smoking, targets for intervention are co-occurring substance use and metabolic risk behaviors. CLINICAL TRIALS REGISTRATION: NCT02207036.