Youth and adult understanding of public displays of information about harmful constituents in cigarette smoke.

The U.S. FDA is required by law to publicly display a list of harmful and potentially harmful constituents (HPHCs) "by brand and by quantity in each brand and subbrand" in a format that is "understandable and not misleading to a lay person." An online experiment examined youth and adult understanding of which HPHCs are present in cigarette smoke, understanding of health effects of smoking cigarettes, and endorsement of misleading information after viewing HPHC information displayed in one of six formats. We recruited youth (N = 1324) and adults (N = 2904) from an online panel and randomized them to one of six formats of presenting HPHC information. Participants responded to survey items before and after exposure to an HPHC format. Understanding of HPHCs in cigarette smoke and understanding of health effects of cigarette smoking significantly increased pre- to post-exposure for all formats. Respondents (20.6% to 73.5%) endorsed misleading beliefs after exposure to information about HPHCs. Endorsement of the one misleading belief that was measured pre- and post-exposure significantly increased for viewers of four formats. All formats increased understanding of HPHCs in cigarette smoke and the health effects of smoking cigarettes, but some participants endorsed each misleading belief after exposure to HPHC information.

Influence of Warning Statements on Understanding of the Negative Health Consequences of Smoking.

INTRODUCTION: Pursuant to the Tobacco Control Act (TCA), the US Food and Drug Administration (FDA) is developing new cigarette health warnings to convey the negative health consequences of cigarette smoking. AIMS AND METHODS: This study assessed which of 15 revised warning statements (10 on topics similar to TCA statements and 5 on other topics) promoted greater understanding of cigarette smoking risks relative to TCA statements. In February 2018, adolescent and adult smokers and adolescents susceptible to smoking (n = 2505) completed an online experiment. Control condition participants viewed TCA statements; treatment condition participants viewed combinations of TCA and revised statements. Analyses compared revised statements to TCA statements on the same health topic or to randomly selected TCA statements if there were no statements on the same topic. RESULTS: Relative to TCA statements, 12 of 15 revised statements were more likely to be considered new information, and 12 resulted in more self-reported learning. Three revised statements made participants think more about health risks than TCA statements; the reverse was true for one revised statement. Participants rated most TCA and revised statements as moderately believable and informative. Seven revised statements were found to be less believable and factual, and one revised statement more believable and factual. Treatment condition participants correctly selected more smoking-related health conditions than control condition participants (13.79 versus 12.42 of 25). CONCLUSIONS: Findings suggest that revised statements can promote greater understanding of cigarette smoking risks. Results informed FDA's selection of warning text that was paired with images for testing in a follow-up study. IMPLICATIONS: The US FDA may adjust the text of the cigarette warning statements provided in the TCA if the revised statements promote greater public understanding of the negative health consequences of cigarette smoking. Most of the revised warning statements tested were more likely to be considered new information and resulted in more self-reported learning compared with paired TCA statements, providing support for using revised statements as part of cigarette health warnings. These results informed the development of pictorial cigarette warnings by FDA that were tested in a follow-up study and included in a proposed rule.

Impact of Pictorial Cigarette Warnings Compared With Surgeon General's Warnings on Understanding of the Negative Health Consequences of Smoking.

INTRODUCTION: The Family Smoking Prevention and Tobacco Control Act requires cigarette packages and advertisements to bear health warnings with "color graphics depicting the negative health consequences of smoking." AIMS AND METHODS: This study assessed whether new US Food and Drug Administration developed pictorial cigarette warnings (PCW) increased understanding of smoking-related risks relative to the current Surgeon General's (SG) warnings. In March-May 2019, adolescent and adult smokers and nonsmokers participated in an online experiment with three sessions completed over approximately 2 weeks. Participants viewed 1 of 16 PCW (treatment conditions) or an SG warning (control) on mock cigarette packages and advertisements. Measures assessed whether warnings provided new information, induced thinking about risks, changed smoking-related health beliefs, and were accurately recalled, among other outcomes. RESULTS: The majority of PCW (≥13 conditions) resulted in greater learning of new information, higher self-reported learning, and greater reports of thinking about smoking risks; they were viewed as more informative, understandable, and attention-drawing compared with the control condition. Most participants believed the warning were factual, although 8 PCW were perceived as less factual than the control. There were changes toward more agreement with health beliefs for 11 PCW between Sessions 1 and 2 and 7 PCW between Sessions 1 and 3. Participants in all treatment conditions were more likely than control condition participants to correctly recall the warning. Across outcomes, PCW related to addiction, death, and quitting did not perform as well as other PCW. CONCLUSIONS: Many of the PCW tested increased understanding of the risks associated with cigarette smoking relative to current SG warnings. IMPLICATIONS: The Tobacco Control Act requires cigarette packages and advertisements to bear PCW depicting the negative health consequences of smoking. This study tested whether any of 16 newly proposed PCW increased understanding of smoking-related risks relative to existing SG warnings. Results suggest that most PCW tested, particularly those related to less widely known health effects, resulted in greater learning of new information, higher self-reported learning, and greater reports of thinking about smoking risks compared with SG warnings. These results, along with other factors, informed the US Food and Drug Administration's selection of proposed PCW.

Adolescents' Use of Basic, Intermediate, and Advanced Device Types for Vaping.

Introduction: Advanced vaping devices likely pose a greater risk to adolescent health than basic or intermediate devices because advanced devices deliver nicotine more effectively and heat e-liquid to higher temperatures, producing more harmful chemical emissions. However, little is known about adolescents' risk factors for using different device types. Methods: We used social media to recruit an online sample of 1508 US adolescents aged 15-17 who reported past 30-day use of electronic vaping products (EVPs) in September 2016. We assessed tobacco use, beliefs, and knowledge about EVPs and EVP use behavior, including the device type participants use most frequently. We used multinomial logistic regression to examine differences between adolescents who usually use intermediate versus basic and advanced versus basic devices. Results: Most respondents usually used modifiable advanced devices (56.8%) rather than basic "cigalike" (14.5%) or pen-style intermediate (28.7%) devices. Use of multiple device types was common, particularly among those who primarily used basic devices. Younger age and less frequent vaping were associated with mainly using basic devices. Adolescents who were older, male, personally bought their main device, and had ever mixed e-liquids were at elevated risk for usually using advanced devices. Conclusions: Adolescents who primarily use basic devices may be newer users who are experimenting with multiple devices. Future research should examine which adolescents are most likely to transition to advanced devices in order to develop targeted interventions. Regulators should consider strategies to reduce access to all types of EVPs, such as better enforcement of the current ban on sales to minors. Implications: This research addresses two gaps in research on adolescent electronic vaping product use: (1) characterizing use of advanced devices as distinct from intermediate devices rather than grouping them together and (2) examining factors associated with use of specific device types. This study suggests that there are distinct profiles of adolescents who use primarily basic, intermediate, or advanced devices. Adolescents who most often use basic devices may be new users experimenting with vaping, whereas adolescents who most often use advanced devices appear to be buying devices for themselves and engaging in risky behaviors such as mixing their own e-liquid.

Latent Class Analysis of E-cigarette Use Sessions in Their Natural Environments.

BACKGROUND: Delivery of nicotine and substances from electronic nicotine delivery systems, or e-cigarettes, depends in part on how users puff on the devices. Little is known about variation in puffing behavior to inform testing protocols or understand whether puffing behaviors result in increased exposure to emissions. METHODS: We analyzed puff topography data collected using a wireless portable use monitor (wPUM) continuously over 2 weeks among 34 current second-generation e-cigarette users in their everyday lives. For each puff, the wPUM recorded date, time, duration, volume, flow rate, and inter-puff interval. RESULTS: We defined use session and classes at the session level using multilevel latent profile analysis, resulting in two session classes and three person types. Session class 1 ("light") was characterized by 14.7 puffs per session (PPS), low puff volume (59.9 ml), flow rate (28.7 ml/s), and puff duration (202.7 s × 100). Session class 2 ("heavy") was characterized by 16.7 PPS with a high puff volume (290.9 ml), flow rate (71.5 ml/s), and puff duration (441.1 s × 100). Person class 1 had almost exclusively "light" sessions (98.0%), whereas person class 2 had a majority of "heavy" sessions (60.7%) and person class 3 had a majority of "light" sessions (75.3%) but some "heavy" sessions (24.7%). CONCLUSION: Results suggest there are different session topography patterns among e-cigarette users. Further assessment is needed to determine whether some users have increased exposure to constituents and/or health risks because of e-cigarettes. IMPLICATIONS: Our study examines topography characteristics in a users' natural setting to identify two classes of e-cigarette session behavior and three classes of users. These results suggest that it is important for studies on the health effects of e-cigarettes to take variation in user topography into account. It is crucial to accurately understand the topography profiles of session and user types to determine whether some users are at greater exposure to harmful or potentially harmful constituents and risks from e-cigarettes as they are used by consumers.

"That's probably what my mama's lungs look like": how adolescent children react to pictorial warnings on their parents' cigarette packs.

BACKGROUND: Pictorial cigarette pack warnings discourage smoking, but most evidence comes from studies of adults. Our qualitative study explored adolescents' reactions to pictorial warnings on their parents' cigarette packs. METHODS: We interviewed 24 adolescents whose parents received pictorial warnings on their cigarette packs as part of a randomized clinical trial. We conducted a thematic content analysis of the interview transcripts. RESULTS: Pictorial cigarette pack warnings led adolescents to imagine the depicted health effects happening to their parents, which elicited negative emotions. The warnings inspired adolescents to initiate conversations with their parents and others about quitting smoking. Adolescents believed the warnings would help smokers quit and prevent youth from starting smoking. Some current smokers said the warnings made them consider quitting. CONCLUSIONS: Conversations about the pictorial warnings may amplify their effectiveness for smokers, their adolescent children, and friends of the adolescent children. Cigarette pack warnings may reach a broad audience that includes adolescent children of smokers.

How hearing about harmful chemicals affects smokers' interest in dual use of cigarettes and e-cigarettes.

Substantial harm could result from concurrent cigarette and e-cigarette use (i.e., dual use) were it to undermine smoking cessation. Perceptions of chemical exposure and resulting harms may influence dual use. We conducted a probability-based phone survey of 1164 U.S. adult cigarette smokers in 2014-2015 and analyzed results in 2016. In a between-subjects experiment, smokers heard a hypothetical scenario in which cigarettes and e-cigarettes had the same amount of harmful chemicals or cigarettes had more chemicals than e-cigarettes (10× more, 100× more, or chemicals were present only in cigarettes). Smokers indicated how the scenario would change their interest in dual use and perceived health harms. Few smokers (7%) who heard that the products have the same amount of chemicals were interested in initiating or increasing dual use. However, more smokers were interested when told that cigarettes have 10× more chemicals than e-cigarettes (31%), 100× more chemicals than e-cigarettes (32%), or chemicals were present only in cigarettes (43%) (all p<.001). Individuals told that cigarettes have more chemicals were more likely than those in the "same amount" scenario to perceive that cigarettes would be more harmful than e-cigarettes (79% vs. 41%, OR=5.41, 95% CI=4.08-7.17). These harm perceptions partially explained the relationship between chemical scenario and dual use interest. Smokers associated higher chemical amounts in cigarettes versus e-cigarettes with greater health harms from cigarettes and thus expressed increased interest in dual use. The findings suggest that disclosing amounts of chemicals in cigarette smoke and e-cigarette aerosol could unintentionally encourage dual use.

Pictorial cigarette pack warnings: a meta-analysis of experimental studies.

OBJECTIVE: To inform international research and policy, we conducted a meta-analysis of the experimental literature on pictorial cigarette pack warnings. DATA SOURCES: We systematically searched 7 computerised databases in April 2013 using several search terms. We also searched reference lists of relevant articles. STUDY SELECTION: We included studies that used an experimental protocol to test cigarette pack warnings and reported data on both pictorial and text-only conditions. 37 studies with data on 48 independent samples (N=33,613) met criteria. DATA EXTRACTION AND SYNTHESIS: Two independent coders coded all study characteristics. Effect sizes were computed from data extracted from study reports and were combined using random effects meta-analytic procedures. RESULTS: Pictorial warnings were more effective than text-only warnings for 12 of 17 effectiveness outcomes (all p<0.05). Relative to text-only warnings, pictorial warnings (1) attracted and held attention better; (2) garnered stronger cognitive and emotional reactions; (3) elicited more negative pack attitudes and negative smoking attitudes and (4) more effectively increased intentions to not start smoking and to quit smoking. Participants also perceived pictorial warnings as being more effective than text-only warnings across all 8 perceived effectiveness outcomes. CONCLUSIONS: The evidence from this international body of literature supports pictorial cigarette pack warnings as more effective than text-only warnings. Gaps in the literature include a lack of assessment of smoking behaviour and a dearth of theory-based research on how warnings exert their effects.

Public understanding of cigarette smoke constituents: three US surveys.

INTRODUCTION: The Tobacco Control Act requires public disclosure of information about toxic constituents in cigarette smoke. To inform these efforts, we studied public understanding of cigarette smoke constituents. METHODS: We conducted phone surveys with national probability samples of adolescents (n=1125) and adults (n=5014) and an internet survey with a convenience sample of adults (n=4137), all in the USA. We assessed understanding of cigarette smoke constituents in general and of 24 specific constituents. RESULTS: Respondents commonly and incorrectly believed that harmful chemicals in cigarette smoke mostly originate in additives introduced by cigarette manufacturers (43-72%). Almost all participants had heard that nicotine is in cigarette smoke, and many had also heard about carbon monoxide, ammonia, arsenic and formaldehyde. Less than one-quarter had heard of most other listed constituents being in cigarette smoke. Constituents most likely to discourage respondents from wanting to smoke were ammonia, arsenic, formaldehyde, hydrogen cyanide, lead and uranium. Respondents more often reported being discouraged by constituents that they had heard are in cigarette smoke (all p<0.05). Constituents with names that started with a number or ended in 'ene' or 'ine' were less likely to discourage people from wanting to smoke (all p<0.05). DISCUSSION: Many people were unaware that burning the cigarette is the primary source of toxic constituents in cigarette smoke. Constituents that may most discourage cigarette smoking have familiar names, like arsenic and formaldehyde and do not start with a number or end in ene/ine. Our findings may help campaign designers develop constituent messages that discourage smoking.

Responses of young adults to graphic warning labels for cigarette packages.

BACKGROUND: In 2010, the US Food and Drug Administration (FDA) proposed a series of 36 graphic warning labels for cigarette packages. We sought to evaluate the effects of the labels on fear-related emotions about health consequences of smoking and smoking motivations of young adults. METHODS: We conducted an experimental study in 2010-2011 with 325 smokers and non-smokers ages 18-30 years whom we recruited through community distribution lists in North Carolina and through a national survey company. Each participant viewed 27 labels (18 of the proposed labels with graphic images and text warnings and 9 with text-only warnings) in a random order, evaluating each label on understandability and its effects on fear-related reactions and discouragement from wanting to smoke. RESULTS: Respondents found most of the proposed labels easy to understand. Of the 36 labels, 64% induced greater fear-related reactions and 58% discouraged respondents from wanting to smoke more than the corresponding text-only labels did. Labels with the greatest effects had photographs (as compared with drawings or other art graphics) or depicted diseased body parts or suffering or dead people. In almost every comparison, smokers reported lower fear-related reactions and feeling less discouraged from wanting to smoke relative to non-smokers. CONCLUSIONS: Most of the proposed labels enhanced fear-related reactions about health consequences of smoking and reduced motivations to smoke relative to text-only labels, although some had larger effects than others. All but one of the nine warning labels recently adopted by the FDA enhanced fear-related reactions and reduced smoking motivations.

How risky is it to use e-cigarettes? Smokers' beliefs about their health risks from using novel and traditional tobacco products.

We sought to understand smokers' perceived likelihood of health problems from using cigarettes and four non-cigarette tobacco products (NCTPs: e-cigarettes, snus, dissolvable tobacco, and smokeless tobacco). A US national sample of 6,607 adult smokers completed an online survey in March 2013. Participants viewed e-cigarette use as less likely to cause lung cancer, oral cancer, or heart disease compared to smoking regular cigarettes (all p < .001). This finding was robust for all demographic groups. Participants viewed using NCTPs other than e-cigarettes as more likely to cause oral cancer than smoking cigarettes but less likely to cause lung cancer. The dramatic increase in e-cigarette use may be due in part to the belief that they are less risky to use than cigarettes, unlike the other NCTPs. Future research should examine trajectories in perceived likelihood of harm from e-cigarette use and whether they affect regular and electronic cigarette use.

Waterpipes and electronic cigarettes: increasing prevalence and expanding science.

The prevalence of non-cigarette tobacco product use is on the rise across the globe, especially for waterpipes (also known as hookah, narghile, and shisha) and electronic cigarettes (e-cigarettes). The scientific literature reveals that waterpipe tobacco smoking is associated with exposure to a variety of toxicants that can cause short- and long-term adverse health events. In contrast, there is far less evidence of health harms related to e-cigarette use, although the variety of products in this category makes it difficult to generalize. We searched the PubMed database for all publications on waterpipes and e-cigarettes from January 2000 to March 2014. The number of publications on waterpipes rose in a slow, linear pattern during this time, while the number of publications on e-cigarettes showed exponential growth. The different trends suggest there may be more interest in studying a novel nicotine product (the e-cigarette) over a traditional tobacco product (the waterpipe). We posit that, although the specific research needs for these products are different, public health would be served best by a more equitable research approach. Scientists should continue to devote attention to understanding the unknown long-term health effects of e-cigarettes and their potential to serve as harm reduction or smoking cessation tools while simultaneously investigating how to reduce waterpipe smoking given that it exposes users to toxicants known to cause harm to health. Recent regulatory action in the United States, which proposes to include waterpipes and e-cigarettes under some of the same regulations as tobacco cigarettes, makes such research particularly timely.

How U.S. adults find out about electronic cigarettes: implications for public health messages.

INTRODUCTION: Electronic cigarettes (e-cigarettes) are battery-powered nicotine delivery systems that have become increasingly popular in the United States. We sought to understand how U.S. adults hear about e-cigarettes. METHODS: A national sample of 17,522 U.S. adults (≥ 18 years old) completed an online survey in March 2013 assessing their awareness of and sources of information about e-cigarettes. RESULTS: Most respondents (86%) had heard of e-cigarettes. Current and former smokers were more likely to be aware of e-cigarettes than non-smokers. Males, younger adults, non-Hispanic Whites, and those with higher education were also more likely to have heard of e-cigarettes. The most commonly reported sources of information were another person, ads on television, and seeing e-cigarettes being sold, although the relative frequency of these sources differed for current, former, and never-smokers. Former and current smokers were more likely to have heard about e-cigarettes from e-cigarette users than were never-smokers. Adults age 30 years or younger were more likely than adults older than 30 years to have heard about e-cigarettes online. CONCLUSIONS: Nearly all U.S. adults had heard of e-cigarettes in 2013. By focusing on the most common channels of information, public health campaigns can more efficiently communicate information about e-cigarette safety and consider necessary regulations should companies use these channels for marketing that targets youth, non-tobacco users, and other at-risk groups.

Electronic nicotine delivery system (electronic cigarette) awareness, use, reactions and beliefs: a systematic review.

OBJECTIVE: We sought to systematically review the literature on electronic nicotine delivery systems (ENDS, also called electronic cigarettes) awareness, use, reactions and beliefs. DATA SOURCES: We searched five databases for articles published between 2006 and 1 July 2013 that contained variations of the phrases 'electronic cigarette', 'e-cigarette' and 'electronic nicotine delivery'. STUDY SELECTION: Of the 244 abstracts identified, we excluded articles not published in English, articles unrelated to ENDS, dissertation abstracts and articles without original data on prespecified outcomes. DATA EXTRACTION: Two reviewers coded each article for ENDS awareness, use, reactions and beliefs. DATA SYNTHESIS: 49 studies met inclusion criteria. ENDS awareness increased from 16% to 58% from 2009 to 2011, and use increased from 1% to 6%. The majority of users were current or former smokers. Many users found ENDS satisfying, and some engaged in dual use of ENDS and other tobacco. No longitudinal studies examined whether ENDS serve as 'gateways' to future tobacco use. Common reasons for using ENDS were quitting smoking and using a product that is healthier than cigarettes. Self-reported survey data and prospective trials suggest that ENDS might help cigarette smokers quit, but no randomised controlled trials with probability samples compared ENDS with other cessation tools. Some individuals used ENDS to avoid smoking restrictions. CONCLUSIONS: ENDS use is expanding rapidly despite experts' concerns about safety, dual use and possible 'gateway' effects. More research is needed on effective public health messages, perceived health risks, validity of self-reports of smoking cessation and the use of different kinds of ENDS.

Effects of advertisements on smokers' interest in trying e-cigarettes: the roles of product comparison and visual cues.

INTRODUCTION: Electronic cigarettes (e-cigarettes) are battery-powered nicotine delivery devices that have become popular among smokers. We conducted an experiment to understand adult smokers' responses to e-cigarette advertisements and investigate the impact of ads' arguments and imagery. METHODS: A U.S. national sample of smokers who had never tried e-cigarettes (n=3253) participated in a between-subjects experiment. Smokers viewed an online advertisement promoting e-cigarettes using one of three comparison types (emphasising similarity to regular cigarettes, differences or neither) with one of three images, for nine conditions total. Smokers then indicated their interest in trying e-cigarettes. RESULTS: Ads that emphasised differences between e-cigarettes and regular cigarettes elicited more interest than ads without comparisons (p<0.01), primarily due to claims about e-cigarettes' lower cost, greater healthfulness and utility for smoking cessation. However, ads that emphasised the similarities of the products did not differ from ads without comparisons. Ads showing a person using an e-cigarette created more interest than ads showing a person without an e-cigarette (p<0.01). CONCLUSIONS: Interest in trying e-cigarettes was highest after viewing ads with messages about differences between regular and electronic cigarettes and ads showing product use. If e-cigarettes prove to be harmful or ineffective cessation devices, regulators might restrict images of e-cigarette use in advertising, and public health messages should not emphasise differences between regular and electronic cigarettes. To inform additional regulations, future research should seek to identify what advertising messages and features appeal to youth.

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

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

Longitudinal predictors of human papillomavirus vaccination among a national sample of adolescent males.

OBJECTIVES: We conducted a longitudinal study to examine human papillomavirus (HPV) vaccine uptake among male adolescents and to identify vaccination predictors. METHODS: In fall 2010 and 2011, a national sample of parents with sons aged 11 to 17 years (n = 327) and their sons (n = 228) completed online surveys. We used logistic regression to identify predictors of HPV vaccination that occurred between baseline and follow-up. RESULTS: Only 2% of sons had received any doses of HPV vaccine at baseline, with an increase to 8% by follow-up. About 55% of parents who had ever received a doctor's recommendation to get their sons HPV vaccine did vaccinate between baseline and follow-up, compared with only 1% of parents without a recommendation. Fathers (odds ratio = 0.29; 95% confidence interval = 0.09, 0.80) and non-Hispanic White parents (odds ratio = 0.29; 95% confidence interval = 0.11, 0.76) were less likely to have vaccinated sons. Willingness to get sons HPV vaccine decreased from baseline to follow-up among parents (P < .001) and sons (P = .003). CONCLUSIONS: Vaccination against HPV remained low in our study and willingness to vaccinate may be decreasing. Physician recommendation and education about HPV vaccine for males may be key strategies for improving vaccination.

The Impact of Social Media Use and Gaming on Initiation of Smokeless Tobacco Use Among Rural Male Youth.

PURPOSE: Smokeless tobacco (SLT) use is more common among White male youth in rural locations than among other youth. Previous literature documents risk factors for SLT use (e.g., perceived harm). However, no research has examined whether SLT initiation is associated with the use of social media and video games, despite the high prevalence of those behaviors among adolescent males. METHODS: As part of the evaluation of "The Real Cost" smokeless prevention campaign, we conducted a baseline survey of a cohort of US males aged 11-16 in 2016 and four follow-up surveys conducted approximately every 8 months. We used discrete-time survival analysis to examine factors associated with SLT initiation. Logistic regression estimated the odds of initiation as a function of lagged values of key predictors (social media use in tertiles and frequency of gaming) and other baseline and lagged correlates. The model controlled for campaign exposure. RESULTS: Relative to the lowest tertile of social media use, moderate (odds ratio [OR] = 1.80) or high use (OR = 2.77) was associated with increased risk of SLT initiation at the subsequent survey wave. Relative to playing every few weeks or less, playing video games once a day (OR = 0.50) or several times a day (OR = 0.33) was associated with decreased risk of SLT initiation. DISCUSSION: SLT initiation was positively associated with social media use and negatively associated with gaming. Future research should explore reasons for the protective nature of gaming (e.g., social support, improved mood) and whether parental supervision of social media use could mitigate its negative impact.

Advertisements promoting human papillomavirus vaccine for adolescent boys: does source matter?

OBJECTIVES: Many parents recall hearing of human papillomavirus (HPV) vaccine through drug company advertisements. This study sought to examine whether parents accurately recall the source (ie, sponsor) of advertisements promoting HPV vaccine and the impact of drug company advertisements. METHODS: A U.S. national sample of 544 parents of adolescent boys aged 11-17 participated in an online between-subjects experiment. Parents viewed an advertisement encouraging HPV vaccination for boys with a logo from a randomly assigned source. Parents rated trust, likability and motivation for vaccination while viewing the advertisement and later indicated who they believed sponsored it. RESULTS: Nearly half (43%) of parents who viewed a hypothetical advertisement containing a logo incorrectly identified the advertisement source. More parents correctly identified the source of drug company advertisements than advertisement from other sources (62% vs. 25%, OR 4.93, 95% CI 3.26 to 7.46). The majority of parents who saw a logo-free advertisement believed a drug company created it (60%). Among parents who correctly identified the advertisement source, drug company advertisements decreased motivation to vaccinate their sons, an association mediated by reduced liking of and trust in the advertisements. CONCLUSIONS: Parents were more accurate in identifying drug company advertisements, primarily because they tended to assume any advertisement was from a drug company. Public health organisations may need to take special measures to ensure their messages are not perceived as sponsored by drug companies.

Does adherence-related support from physicians and partners predict medication adherence for vasculitis patients?

Few studies have explored mediators between medication-related support and medication adherence for individuals with rare, systemic autoimmune conditions. Using the Information-Motivation-Behavioral Skills model, we tested whether depressive symptomatology and medication adherence self-efficacy mediated the relationship between adherence support and changes in medication adherence among vasculitis patients, and whether support from physicians and partners differentially affected medication adherence. Vasculitis patients (n = 172) completed baseline and follow-up questionnaires about their medication adherence and perceived adherence support. Bootstrapped mediation analyses tested the effects of physician and partner support on changes in medication adherence. Adherence self-efficacy mediated the relationship between physician support and changes in medication adherence (B = 0.05, SE = 0.03, 95% CI 0.01, 0.13). Neither self-efficacy nor depressive symptomatology mediated the effects of partner support. Although physicians spend little time with patients, they can increase patients' confidence about taking medications correctly and potentially improve health outcomes by bolstering medication adherence.