Changes to cigarette packaging influence US consumers' choices: Results of two discrete-choice experiments to inform regulation.

INTRODUCTION: While plain packaging of tobacco products has emerged as a policy intervention to reduce smoking, regulators in the US have limited ability to implement plain packaging. We sought to identify the impact of subtle changes to cigarette packaging (Study 1) and how packaging design influenced participant choices based on appeal, harm, and style (Study 2). METHODS: We conducted two discrete-choice experiments with US adult smokers online in 2018. In Study 1 (n=285), we assessed participants' selections based on subtle changes to pack design features (dimensions, color saturation, logo size). In Study 2 (n=284), we assessed three choices in which participants selected packs based on appeal, harmfulness, and best match to their personal style. Study 2 packs varied by color hue, design with different levels of organic labeling and natural imagery, and color saturation. RESULTS: Pack designs influenced smokers' choices. In Study 1, pack dimensions and color saturation emerged as the most important features, and, in Study 2, design and color hue were the most influential characteristics. CONCLUSIONS: Regulators should consider how the design of cigarette packages may influence consumers' perceptions and choices.

Barriers to and Facilitators of Oral Health Among Persons Living With Mental Illness: A Qualitative Study.

OBJECTIVE: Persons with mental illness have poorer oral health and are less likely to receive oral health care than those in the general population. A comprehensive understanding of barriers to and facilitators of accessing oral health care from a multidisciplinary perspective is lacking. The authors of this qualitative study sought to explore barriers and facilitators in addressing the oral health needs of individuals with mental illness from the perspectives of patients, psychiatrists, and dentists. METHODS: A thematic content analysis approach was used to triangulate the perspectives of the three groups. Face-to-face semistructured interviews were conducted in 2018-2019 with patients with mental illness (N=20), psychiatrists (N=20), and dentists (N=25) at an academic medical campus in rural eastern North Carolina. Participants were recruited until thematic saturation for each group was reached. RESULTS: Reported barriers to oral health care were categorized under emerging themes: access to dental care, fear of dental care, characteristics of mental illness, lack of oral health screening by psychiatrists, lack of education and training, stigma of mental illness, and lack of communication. Facilitators of oral health care were linked to the reported need for education and training, financial support, dentists' chairside manner, community support, and interprofessional communication. CONCLUSIONS: The findings highlight health system gaps between oral health and mental health. The barriers and facilitators identified can help inform the development of interventions to improve oral health of patients with mental illness. Interventions should include interdisciplinary education and training, improved communication, and strategies to reduce financial barriers and anxiety in dental practice.

Characteristics of Medical School Applicants: A Single-Institution Study.

BACKGROUND AND OBJECTIVES: Medical schools aim to admit talented learners who are honest, patient centered, and caring, in addition to possessing the required cognitive skills. The Association of American Medical Colleges (AAMC) describes core competencies for entering medical students in three categories: science, preprofessional, and thinking and reasoning. The authors sought to determine desired characteristics of medical school applicants at a rural, community-based medical school in light of the published core competencies. METHODS: This qualitative study involved an analysis of data from discussion groups, all from a convenience sample of participants. The authors led the discussion groups, and large sticky note pads and pens were provided to scribe responses. Group members were given the prompt, "What do you see as traits or characteristics of your ideal doctor?" We used a content analysis approach to analyze the data. RESULTS: The total number of responses across groups was 243, representing 15 unique characteristics. The 15 characteristics, listed in decreasing order of frequency, included good communicator, knowledgeable, dedicated, compassionate, respectful, community oriented, well rounded, patient, team player, available, leader, positive attitude, equal treatment, prevention focused, and urgency when needed for patient care. Of the top characteristics with 20 or more responses, alignment with AAMC competencies was noted, but less so with being community oriented as defined by study participants. CONCLUSIONS: This study demonstrates that there are unique characteristics that a rural community and its medical school consider when admitting applicants to their medical program. Further research is needed to explore the need for additional competencies for rural medical schools to consider for entering medical students.

Assessing the Potential Impact of Cigarette Packs Designed for Lesbian, Gay, Bisexual, and Transgender Adults: A Randomized Experiment to Inform U.S. Regulation, 2018.

The Food and Drug Administration (FDA) can regulate the introduction of new tobacco products and some changes to existing products. Cigarette packs have been used as a marketing tool to target specific groups and priority populations. Research has shown that sexual and gender minority (SGM) adults are substantially more likely to use tobacco products than their straight and cisgender counterparts. However, research to inform the FDA's regulatory decisions regarding cigarette packs targeting priority populations is nascent. To fill this gap, we conducted an online experiment in 2018, randomizing U.S. adults who reported current smoking (N = 954, 52% were SGM) to view one of three cigarette packs. A graphic designer developed "Glacier" branded packs with three levels of SGM imagery: (1) no targeting, (2) subtle targeting, and (3) a rainbow "pride edition." Participants viewed and rated the pack using cognitive, affective, and behavioral measures informed by theory. We used a linear model framework to compare the two SGM-targeted packs with the not targeted version and tested interactions between pack and SGM identity for the dependent variables. We stratified results by SGM status. SGM status was a significant moderator of the relationship between the pack and ratings of appeal, positive affect, feeling shocked, and intent to try with a coupon. Findings from this study revealed that packs designed for SGM populations can disproportionately change cognitive, affective, and behavioral intention responses for SGM smokers. Products entering the market should be assessed by FDA for the appeal of their packs to vulnerable populations.

Meaningful Patient Care Experiences for Minority Graduate School Students.

BACKGROUND: Increasing numbers of underrepresented in medicine minority (URMM) physicians has garnered increased attention. Pipeline programs aid this effort and are designed to expose learners to the healthcare experience and strengthen academic preparedness. This paper describes the clinical experiences of students who participated in a bridge to medical school Master's Degree pipeline program at a community based medical school. METHODS: Using qualitative methodology, the authors sought to explore the clinical experiences of three cohorts of graduate school pipeline students on a path to medical school. Thirty six master's level students responded to an evaluation of opened-ended questions at the conclusion of their clinical preceptorship. The responses to three open-ended questions were analyzed via the constant comparison analysis method. RESULTS: The total number of clinical encounters during the clinical preceptorship over the three-year period was 633, a total of 144 h. The most common diagnoses seen were related to cardiovascular disease and diabetes. Three primary themes were identified regarding students' experiences in the pipeline program: connecting academic and clinical skills, learning the needs of and how to advocate for underserved patients and the need to increase exposure to underserved patient populations across specialties in medicine. CONCLUSIONS: The clinical preceptorship linked academic knowledge with clinical skills and provided an avenue for learning about health disparities and patient advocacy for underserved patients. It also identified a need for increased exposure to underserved patient populations across medical specialties.

Evolving IQOS packaging designs change perceptions of product appeal, uniqueness, quality and safety: a randomised experiment, 2018, USA.

BACKGROUND: Globally, the tobacco industry is promoting heated tobacco products. These products may represent a strategy to promote dual use of tobacco products. One product, IQOS from Philip Morris International, is being proposed in the USA for marketing as a less harmful product. The visual design of tobacco products can influence consumers by implying product characteristics. Thus, we sought to test the impact of IQOS packaging designs on cognitive, affective and behavioural intention responses. METHODS: From existing IQOS packages used globally, we developed three IQOS packages that decreasingly linked the product to the Marlboro brand. In September to October 2018, we assigned participants randomly to one package in an online experiment. All participants (n=954) were US adults reporting current smoking and no colour blindness. The experiment used quota sampling to ensure diversity by gender, sexual orientation, race, ethnicity and education. Measures were informed by the Context of Consumption Framework. To assess differences in ratings, we conducted non-parametric Kruskal-Wallis tests with post hoc comparisons using Dunn's test. RESULTS: We found significant differences in cognitive indicators including appeal (H=6.87, p=0.03), uniqueness (H=15.68, p<0.01), brand equity-quality (H=122.35, p<0.01) and perceived safety compared with other tobacco products (H=14.27, p<0.01). Participants rated packages similarly on affective and behavioural intention measures. All were rated low for talking to others about the product and high for interest in trying with a coupon. CONCLUSION: Linking or separating IQOS products with a well-established cigarette brand changes how adult smokers respond to the product. Regulators should consider the visual design of packaging.

"The Packaging Is Very Inviting and Makes Smokers Feel Like They're More Safe": The Meanings of Natural American Spirit Cigarette Pack Design to Adult Smokers.

BACKGROUND/AIMS: The aim of this investigation was to identify which design elements on Natural American Spirit packs are salient to (i.e., noticed by) U.S. adult smokers and what meanings smokers derive from these elements. METHOD: We conducted a secondary analysis of qualitative data from a study of cigarette packaging design. U.S. adult smokers ( n = 33) from all nine census regions participated in six telephone-based focus groups in March 2017. We used constant comparison analysis to identify key themes. RESULTS: Four themes were identified, two focused on salient design elements and two focused on design element meanings. The themes of "bright and flashy color" and "the American Indian logo" were identified as key design elements, while the themes of "healthy and safer" and "targeting at-risk smokers" were identified as meanings smokers derived from design elements. CONCLUSIONS: Pack design elements influence smokers' perceptions about reduced health risk of Natural American Spirit cigarettes and may be especially dangerous to vulnerable populations, including young adults and American Indians. Findings from this study suggest that the banning of text descriptors may not be enough to address misconceptions about "healthier" cigarettes.

Messaging Lesbian, Gay, Bisexual, and Transgender Health Inequities: A Qualitative Exploration.

BACKGROUND: There are substantial health inequities for lesbian, gay, bisexual, and transgender (LGBT) people compared to their straight/cisgendered counterparts. As evidence of these inequities has become unequivocal, better strategies to address them are needed. One approach is to leverage communications and media advocacy efforts to raise awareness about inequities. However, some research suggests that highlighting health inequities can have negative consequences. This study aimed to explore how LGBT leaders view communication about health inequities. METHOD: We used an inductive qualitative approach and conducted 12 semistructured phone interviews with LGBT community leaders in North Carolina between September and October 2017. RESULTS: Four themes emerged in the data. There was support for reporting health differences between LGBT and straight/cisgendered people to raise awareness of health issues facing LGBT communities. However, participants were concerned about the stigmatizing effects of messages and worried about their effectiveness. CONCLUSION: Emphasizing health differences between LGBT and straight people can be problematic; our findings suggest that health educators (1) must be cautious, (2) must be aware of the audience, and (3) should consider focusing messages on finding a solution to the identified problem. Future work should explore how to best craft messages that address health inequities for LGBT communities.

Qualitative assessment of a Context of Consumption Framework to inform regulation of cigarette pack design in the U.S.

INTRODUCTION: Researchers and regulators need to know how changes to cigarette packages can influence population health. We sought to advance research on the role of cigarette packaging by assessing a theory-informed framework from the fields of design and consumer research. The selected Context of Consumption Framework posits cognitive, affective, and behavioral responses to visual design. To assess the Framework's potential for guiding research on the visual design of cigarette packaging in the U.S., this study seeks to understand to what extent the Context of Consumption Framework converges with how adult smokers think and talk about cigarette pack designs. METHODS: Data for this qualitative study came from six telephone-based focus groups conducted in March 2017. Two groups consisted of lesbian, gay, and bisexual participants; two groups of participants with less than four years college education; one group of LGB and straight identity; and one group the general population. All groups were selected for regional, gender, and racial/ethnic diversity. Participants (n=33) represented all nine U.S. Census divisions. We conducted a deductive qualitative analysis. RESULTS: Cigarette package designs captured the participants' attention, suggested the characteristics of the product, and reflected (or could be leveraged to convey) multiple dimensions of consumer identity. Particular to the affective responses to design, our participants shared that cigarette packaging conveyed how the pack could be used to particular ends, created an emotional response to the designs, complied with normative expectations of a cigarette, elicited interest when designs change, and prompted fascination when unique design characteristics are used. CONCLUSIONS: Use of the Context of Consumption Framework for cigarette product packaging design can inform regulatory research on tobacco product packaging. Researchers and regulators should consider multiple cognitive, affective, and behavioral responses to cigarette pack design.

Is the cigarette pack just a wrapper or a characteristic of the product itself? A qualitative study of adult smokers to inform U.S. regulations.

PURPOSE: In the U.S., tobacco products are now regulated by the Food and Drug Administration (FDA). Litigation has quickly followed. One area of controversy is when a change to the design of the cigarette pack requires approval through FDA's rigorous premarket review process. In this paper, we examine how adult U.S. smokers view the connection between the design of cigarette packs and the characteristics of the cigarettes within. METHODS: Data for this qualitative study came from six focus groups conducted in March 2017 with adult smokers. Two groups consisted of lesbian, gay, and bisexual (LGB) participants; two groups of participants with less than four years of college education; one group of LGB and straight identity; and, one group of the general population. All groups were selected for regional, gender, and racial/ethnic diversity. Participants (n = 33) represented all nine U.S. Census divisions. We conducted constant comparison qualitative analysis utilizing a grounded theory approach. RESULTS: Participants' views reflected a belief that pack design is clearly a reflection of the cigarettes within and that a change in the pack signaled a change in the cigarettes. However, some participants felt price was the salient characteristic of cigarettes and design mattered more for enticing young people to smoke. CONCLUSIONS: Changes in pack design signal changes to the product for smokers. Pack design and changes to pack design are seen as particularly relevant to new and young smokers. These findings provide support for regulations that require assessment of cigarette pack design changes for impacts on public health.

"Their Packaging Has Always Been Like a Power": A Qualitative Study of U.S. Smokers' Perceptions of Cigarette Pack Visual Design Features to Inform Product Regulation.

Cigarette packaging matters to consumer behavior. However, it is less clear which changes to packaging design would be salient for adult smokers. Such information is critically important to regulators in the United States who are charged with reviewing new tobacco products for their impact on population health. In this qualitative study, U.S. adult smokers (n = 33) participated in six telephone-based focus groups in March 2017. Separate groups were comprised of lesbian, gay, and bisexual (LGB) participants; participants with less than four years of post-secondary education; a mix of LGB and straight participants; and, the general population. All groups were purposely selected for diversity. Open thematic coding identified salient design elements used on cigarette packaging. Smokers articulated design elements' use, meaning, and links with consumer behaviors. Three themes were identified: (1) the power of color, (2) supporting color with other design elements (e.g., logos/images, typography, the pack itself), and (3) the combined product brand experience of multiple design elements. Participants linked design elements to product characteristics and to consumer behavior (e.g., purchase). As the Food and Drug Administration is charged with regulating tobacco products, these findings suggest the importance of considering the cigarette pack part of the characteristics of a product.