Evaluating The Real Cost Digital and Social Media Campaign: Longitudinal Effects of Campaign Exposure on E-cigarette Beliefs.

INTRODUCTION: Over the past decade, youth e-cigarette use has risen exponentially. At the same time, digital media use increased markedly while the use of traditional broadcast TV declined. In response, the U.S. Food and Drug Administration's The Real Cost public education campaign shifted to communicating the harms of e-cigarette via primarily digital and social platforms. This study evaluated longitudinal associations between exposure to campaign advertisements and changes in campaign-specific beliefs among US youth. METHODS: A nationally representative longitudinal cohort of youth (aged 11-16 years at baseline) was surveyed five times. Building on earlier work, we analyzed data from the last three waves (April-July 2020; January-April 2021; and August-October 2021; N = 2625). We assessed self-reported exposure to six ads and agreement with 11 beliefs that were each targeted by one or more ads. Eleven weighted panel regression models assessed whether ad exposure predicted changes in campaign-specific beliefs over time. RESULTS: We observed significant associations between ad exposure and increases in at least one campaign-specific belief for five of the six ads. Across the 11 beliefs, we observed associations between increased exposure and increases in 6 beliefs related to e-cigarettes and toxic metals, lung damage, dangerous ingredients, anxiety, cigarette use, and disappointing important people. CONCLUSIONS: We found evidence that self-reported exposure to this digital and social media campaign was successful at influencing youth, providing support for the effectiveness of the campaign's adaption to address youth's changes in tobacco and media use habits. IMPLICATIONS: The Food and Drug Administration's The Real Cost public education campaign educates youth about the dangers of e-cigarette use. This study evaluates longitudinal associations between exposure to The Real Cost's advertisements and changes in campaign-specific beliefs among youth. Considering evolving trends in youth media consumption, the campaign adapted its media approach to increase delivery across digital and social media platforms. Our findings indicate that the campaign reached its intended audience and increased youth beliefs around the harm of e-cigarettes and the consequences of e-cigarette use, offering evidence for the effectiveness of digital and social media youth prevention efforts within a fragmented digital environment.

Youths' Perceptions of Nicotine Harm and Associations With Product Use.

INTRODUCTION: Although nicotine is the main addictive substance in tobacco, tobacco combustion is responsible for most tobacco-related diseases. U.S. adults hold misperceptions about nicotine harm. However, little is known about youth nicotine perceptions. AIMS AND METHODS: To address this gap, we assessed U.S. youths' nicotine perceptions and how these perceptions relate to tobacco use. Participants were youth (ages 12-17) in waves 4 (w4; December 2016-January 2018; N = 14 798) and 4.5 (w4.5; December 2017-December 2018; N = 12 918) of the Population Assessment of Tobacco and Health Study, a nationally representative longitudinal cohort study. We describe beliefs about nicotine; perceptions of the nicotine harm in cigarettes, e-cigarettes, and nicotine replacement therapy (NRT); and demographic differences. Regressions assess whether w4 nicotine perceptions predicted w4.5 tobacco use. RESULTS: Most youth correctly responded that nicotine is the main cause of addiction (77.1%) but incorrectly responded that nicotine is the main substance that causes smoking-related cancer (74.7%). Youth distinguished between the harm of nicotine in different products, and on average rated the nicotine in cigarettes as most harmful, followed by e-cigarettes and NRT. Among youth who did not use at w4, greater harm perceptions of nicotine in cigarettes, e-cigarettes, and NRT were associated with lower likelihood of reporting current tobacco use at w4.5. Among youth who currently used cigarettes or e-cigarettes at wave 4, nicotine perceptions did not predict switching to e-cigarettes or cigarettes, respectively, at wave 4.5. CONCLUSIONS: These findings underscore the challenge of developing effective and comprehensive communication strategies that accurately convey the effects of nicotine without encouraging tobacco use. IMPLICATIONS: Many U.S. adults have misperceptions about nicotine, incorrectly believing it is the substance that causes most smoking-related cancers; studies have not assessed youth's perceptions of nicotine and how these perceptions relate to tobacco use. This study found that similar to adults, most youth incorrectly believed nicotine is the main substance that causes smoking-related cancer; youth also distinguish between the harmfulness of nicotine in different products, and rated the nicotine in cigarettes as most harmful, followed by e-cigarettes and NRT. Perceptions of the harm in different nicotine and tobacco products negatively predicted becoming a person who used tobacco a year later, but did not predict switching between e-cigarettes and cigarettes. Findings highlight the challenges of accurately communicating about the harms of nicotine without encouraging tobacco use; findings can be considered in the context of FDA's potential nicotine product standard that would lower nicotine levels in combustible tobacco products to a minimally or nonaddictive level.

The effect of cigarette modified risk claims and brand on perceived risk, product appeal, and use intentions.

OBJECTIVES: No studies have examined the brand context in which modified risk claims appear on tobacco products. This study examines how marketing products with modified risk claims affects risk perceptions, appeal, and intentions among own-brand, other brand, and novel brand cigarettes. METHODS: This experiment employed a 3 (claim: risk modification [RM], exposure modification [EM], control) x 3 (brand: own, other, novel) between-subjects design. A convenience sample (N = 1,557, Mage = 40.28, SDage = 19.01, 71.3% female, 80.3% White) of current or former Marlboro, Camel, or Newport users was collected. Participants were assigned to view their own brand, another brand, or a novel brand, with or without a claim, and rated perceived risk after switching to this product, product appeal, and use intentions. RESULTS: Participants in the RM or EM conditions had lower risk perceptions (versus control). Claim did not affect appeal. Adult established cigarette users in the EM (but not RM) condition had higher intentions (versus control). Participants rated their own and another brand as more appealing than the novel brand. Interactions between brand and claim were not significant. CONCLUSIONS: We found modified risk claims decreased risk perceptions but did not impact appeal. Whereas participants showed preference for their own brand in terms of appeal and intentions, brand did not moderate the impact of claims.

Predicting tobacco product initiation from intentions to use: Comparing the validity of item analysis methods.

Items measuring tobacco use intentions are used to predict future use. Researchers combine items using different methods; however, no research has compared these methods' predictive validity. Here, we compare how well six methods of analyzing four intention items predict initiation of cigarettes, e-cigarettes, snus pouches, and other smokeless tobacco one year later. We analyzed youth and young adult never users from the US Population Assessment of Tobacco and Health Study. We compared six methods of analyzing Wave 3 intention items in predicting Wave 4 use: susceptibility scoring (susceptible is not answering "definitely no" to all items); dichotomizing the four-item average using two cut-points on the 1-4 response scale; and dichotomizing one item (next year use intention) with three cut-points. Analyses (1) tested whether each single-item predicted initiation; and (2) compared each method's (a) true positive rate (rate of correctly identifying future initiators), (b) true negative rate (rate of correctly identifying future non-initiators), and (c) model fit. Results were similar across products and age groups. Averaging items best predicted initiation in regression. Susceptibility scoring had the highest true positive rate but lowest true negative rate. False positives (incorrectly identifying someone as a future initiator) were best minimized by averaging items with a cutoff of 3, or using the single item with a 3 or 4 cutoff. Findings suggest researchers predicting tobacco use initiation using regression should average the four items; and researchers seeking to identify likely initiators should use different analytic methods depending on if they seek to maximize true positives or minimize false positives.

Developing and Validating Measures of Absolute and Relative E-Cigarette Product Risk Perceptions: Single Items Can Be Surprisingly Comprehensive.

INTRODUCTION: Tobacco risk perceptions are important predictors of behavior and are impacted by tobacco communications. Our systematic literature review (completed in 2018) found there were no measures of e-cigarette risk perceptions that were completely consistent with tobacco researcher recommendations (eg, specifying use frequency) and had demonstrated validity and reliability. The current study develops measures to assess specific risk perceptions, including absolute risks and risks compared with cigarettes, nicotine replacement therapy, and all nicotine cessation. METHODS AND RESULTS: We generated a list of tobacco health effects based on our previous systematic review of tobacco risk perception measures. Based on health effects prioritized by regulatory science experts, we developed 63 items to assess seven types of e-cigarette risk perceptions: absolute health and addiction risks, health and addiction risks relative to cigarettes, pregnancy health risks relative to cigarettes, health risks relative to nicotine replacement therapy, and health risks relative to all nicotine cessation. We fielded these items in an online survey (N = 1642). Through reliability and validity analyses, we reduced this pool to 21 items, including many single-item measures. Supporting the measures' validity, each measure was negatively associated with current e-cigarette use, e-cigarette intentions, and skepticism about e-cigarette harms; and positively associated with perceiving e-cigarettes as equally or more harmful than cigarettes and intentions to quit e-cigarettes. DISCUSSION: This study developed and validated brief measures of several types of e-cigarette risk perceptions. Surprisingly, we found that for many types of risk perceptions, multi-item measures were redundant and these perceptions were well-represented by single-item measures. IMPLICATIONS: This study developed measures of seven types of e-cigarette health risk perceptions, including absolute health and addiction risk, and risk relative to cigarettes, nicotine replacement therapy, and cessation. We reduced 63 items to 21 to measure all of these constructs. These measures follow tobacco researcher recommendations, were developed using a rigorous measures development process, and demonstrated some aspects of reliability and validity. Because these measures are publicly available, they can be used by public health and industry researchers.

Absolute and Relative Smokeless Tobacco Product Risk Perceptions: Developing and Validating New Measures that are Up-to-Snuff.

INTRODUCTION: Tobacco risk perceptions impact behavior. Our 2018 systematic review of tobacco risk perception measures found no measures of smokeless tobacco (ST) risk perceptions with demonstrated validity and complete consistency with tobacco researcher recommendations (e.g. specifying use frequency). This study develops such measures to assess seven specific risk perceptions of market-leading ST products: absolute health and addiction risks, health and addiction risks relative to cigarettes, pregnancy health risks relative to cigarettes, health risks relative to nicotine replacement therapy, and health risks relative to tobacco cessation. METHODS AND RESULTS: We fielded 64 items assessing risk perceptions associated with tobacco in an online survey experiment (N = 2754) that tested effects of exposing participants to a modified risk claim on a leading ST product. Through reliability and validity analyses, we reduced this to 35 items representing seven constructs. Exploratory factor analyses indicated single-factor solutions for all but two constructs: absolute health risk and health risk relative to cigarettes, which were each represented by two-factors (respiratory and oral risks). Participants perceived respiratory risks differently than oral risks: a modified risk claim reduced ST relative respiratory risk perceptions but increased ST perceived oral risks. CONCLUSIONS: Absolute and relative risk perceptions were each represented by two factors that behaved differently, underscoring the utility of assessing respiratory and oral risk perceptions separately. These measures of seven risk perception constructs demonstrated some validity and can be used to assess perceptions of ST risk in future research, such as postmarket surveillance of tobacco products authorized for marketing by FDA. IMPLICATIONS: This study develops and validates publicly available measures of seven smokeless tobacco risk perception constructs: absolute health and addiction risks, health and addiction risks relative to cigarettes, pregnancy health risks relative to cigarettes, health risks relative to nicotine replacement therapy, and health risks relative to tobacco cessation. This study suggests that for both absolute and relative risk perceptions, risks of respiratory and oral health effects should be assessed separately, because these risk perceptions may be impacted differently by modified risk claims, and are differentially related to smokeless tobacco beliefs, use intentions, and current use.

Influencer prevalence and role on cigar brand Instagram pages.

PURPOSE: Influencers market products for tobacco companies on social media. This is the first study to systematically examine leading cigar brands' use of influencers on their brand Instagram pages. METHODS: We identified 24 leading cigar brands, using July 2017-June 2018 US retail data. We identified cigar brands that had official appearing Instagram pages, with at least one influencer in the past 20 posts. We coded characteristics of the past three posts from each of five brand pages that contained influencers, such as setting and what the influencer was doing. Finally, we described influencer characteristics. RESULTS: Approximately one-third of the 24 brands had official Instagram accounts with at least one influencer in the past 20 posts. We identified 28 influencers, typically people of colour from the hip-hop music industry, some with millions of followers. Influencers included Bella Thorne (@bellathorne), Shaquille O'Neal (@shaq) and T.I. (@troubleman31). Brands' posts that contained influencers showed the influencer using/holding a product, wearing branded merchandise or appearing in photos with a brand watermark. Three brands' pages posted sponsored event photos (ie, concerts and events using branded backgrounds). DISCUSSION: Cigar brands commonly use influencers to market their products on brand Instagram pages. Results are consistent with previous findings that cigar companies' marketing may target younger African Americans and highlight the potential utility of education campaigns that similarly engage influencers.

Social media use by leading US e-cigarette, cigarette, smokeless tobacco, cigar and hookah brands.

BACKGROUND: Youth and young adults frequently use social media and are susceptible to tobacco use. This study is the first to provide a systematic overview of how leading tobacco product brands use popular social media platforms. METHODS: We identified 112 leading brands of e-cigarettes, hookah, cigars, cigarettes and smokeless tobacco based on sales and self-report user data. We searched for each brand on six platforms: Instagram, Facebook, Twitter, YouTube, Pinterest and Tumblr. In early 2019, we conducted a content analysis of each page, coding: age restrictions, warning display, page characteristics and post characteristics. RESULTS: Cigarette brands were generally not present. Most e-cigarettes, hookah and cigar brands had pages on at least two platforms. One-third of smokeless brands had pages on at least one platform. Few brands had pages on Pinterest and Tumblr. Most pages had existed for 3-5 years. Overall, brand pages rarely used age gating, did not display health warnings, generally posted images of a product alone and often used hashtags unrelated to tobacco. Brands commonly used special features like ephemeral posts on Instagram and pop-up chat windows on Facebook. Many pages displayed images of young people and mentioned flavour. Median followers per brand ranged from about 1 000-10 000, and total followers summed across brands reached over 5 million on Facebook and Instagram alone. CONCLUSIONS: Leading brands of most tobacco product types use social media extensively. Several findings identify issues related to youth exposure to and appeal of tobacco social media marketing. Findings can inform tobacco education efforts and regulation.

Sexual and Gender Minority U.S. Youth Tobacco Use: Population Assessment of Tobacco and Health (PATH) Study Wave 3, 2015-2016.

INTRODUCTION: Tobacco use disparities by sexual identity are well characterized among adults, but relatively less is known about tobacco use disparities in sexual minority youth. Moreover, no national study has reported tobacco use behaviors among gender minority (e.g., transgender) youth. METHODS: Data from Wave 3 (2015-2016) of the Population Assessment of Health Study from youth aged 14-17 years (n=7,772), analyzed in 2018, were stratified by transgender identity, sex, and sexual identity to describe tobacco product use. RESULTS: Transgender youth (n=79) were more likely to report ever use of tobacco products compared with nontransgender youth (electronic nicotine products, 40.2% vs 23.0%; cigarettes, 33.9% vs 14.1%; and smokeless tobacco, 21.5% vs 6.0%, respectively) and more likely to report past 30-day use of these products. Similarly, female sexual minority youth, compared with straight female youth, were more likely to report ever use of electronic nicotine products (37.9% vs 20.1%); cigarettes (28.9% vs 12.0%); cigars (11.3% vs 5.2%); hookah (12.7% vs 7.6%); and past 30-day use of electronic nicotine products, cigarettes, and cigars. Among male youth, sexual minority youth were more likely to report ever use of cigarettes compared with straight youth (25.1% vs 13.5%), but they did not differ in ever or past 30-day use of any other tobacco products. CONCLUSIONS: Sexual minority youth and transgender youth are more likely to use tobacco products compared with their nonminority peers. Similar to patterns among adults, this is especially true for female sexual minority youth. This information is useful for developing communication and education efforts to prevent youth tobacco initiation in these high-risk groups.

Cigar package quantity and smoking behavior.

BACKGROUND: Several jurisdictions in the US and abroad limit the minimum number of cigars that can be sold per package. Research has not evaluated whether small packages might result in cigar use initiation, or whether adding cigars to packages might result in purchasers smoking more cigars. METHODS: Using nationally representative US adult data from Waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study, we assessed links between cigar package quantity (number of cigars in the package a person usually buys) and (1) price, and (2) cigar and cigarette use over time, for three cigar types: filtered cigars, cigarillos, and large cigars. RESULTS: Smaller quantity packages (i.e., packages with fewer cigars) were cheaper per-pack than larger quantity packages but more expensive per-stick for all three cigar types. For filtered cigars, past-year starters tended to buy smaller quantity packages compared to longer-term users (geometric mean = 6.31 vs. 11.75, respectively; b = -.18, 95%CI: -.32, -.04). Also, those who bought smaller quantity packages of filtered cigars tended to smoke fewer cigars over time compared to those who bought larger quantity packages (b = 1.16, 95%CI: 0.45, 1.87). Neither of these associations was observed for cigarillos or large cigars. We also found little evidence that buying larger quantity packages predicted continuing to use cigars or using cigarettes. CONCLUSIONS: Although we found consistent associations between package quantity and price, we found few associations between package quantity and changes in cigar smoking behaviors over time, particularly for cigarillos and large cigars. Key limitations include our adult-only analyses and inability to determine the package quantity that cigar users initiated with. Future studies could examine whether package quantity plays a causal role in filtered cigar use initiation or consumption rates.

Perceived relative harm of using e-cigarettes predicts future product switching among US adult cigarette and e-cigarette dual users.

BACKGROUND AND AIMS: People's perceptions of the harmfulness of e-cigarettes, compared with cigarettes, may influence their product use decisions. We tested if perceiving e-cigarettes as less harmful than cigarettes predicted whether cigarette and e-cigarette dual users switched their product use status 1 year later, becoming exclusive e-cigarette users, exclusive cigarette smokers, or non-users of both product types. DESIGN: Longitudinal analyses of waves 2 (2014-15) and 3 (2015-16) of the prospective, national Population Assessment of Tobacco and Health (PATH) Study. SETTING: United States. PARTICIPANTS: Adults who reported using both cigarettes and e-cigarettes within the past 30 days at wave 2 reported their perceptions of e-cigarette harm at wave 2, and reported whether they used cigarettes and e-cigarettes within the past 30 days at wave 3 (n = 2211). MEASUREMENTS: The key predictor was wave 2 perceptions of e-cigarette harm compared with cigarettes ('less harmful,' 'about the same', 'more harmful' or 'don't know'). The key outcome was wave 3 past 30-day use of e-cigarettes and cigarettes, classified into four categories: exclusive e-cigarette use (i.e. use of e-cigarettes but not cigarettes), exclusive cigarette smoking (i.e. use of cigarettes but not e-cigarettes), dual use of both product types and non-use of both product types. FINDINGS: At wave 2, 59.4% of dual users perceived e-cigarettes as less harmful than cigarettes [95% confidence interval (CI) = 56.9, 61.9]. Compared with those with other perceptions of e-cigarette harm, dual users who perceived e-cigarettes as less harmful than cigarettes were more likely to become exclusive e-cigarette users 1 year later [7.5 versus 2.7%; adjusted odds ratio (aOR) = 2.9, 95% CI = 1.7-4.8], more likely to remain dual users (39.6 versus 29.9%; aOR = 1.5, 95% CI = 1.2-1.8), less likely to become exclusive cigarette smokers (44.8 versus 59.4%; aOR = 0.6, 95% CI = 0.5-0.7) and similarly likely to become non-users of both product types (8.2 versus 8.0%; aOR = 1.1, 95% CI = 0.7-1.7). CONCLUSIONS: US adult dual users of e-cigarettes and cigarettes who perceive e-cigarettes as less harmful than cigarettes appear to be more likely to switch to exclusive e-cigarette use, more likely to remain dual users and less likely to switch to exclusive cigarette use 1 year later than dual users with other perceptions of e-cigarette harm.

Multi-item Measures of Tobacco Health Perceptions: A Review.

Objective: In this paper, we review multi-item measures of tobacco risk perceptions and health beliefs, describe the measures' content and quality, and identify measure development opportunities. Methods: We identified 110 articles that included measures assessing perceptions of tobacco's health effects by combining multiple items into a score. We coded measures' provenance (newly developed vs built on prior measures), content, consistency with risk-perception researcher recommendations (eg, specifying use conditions), samples used, and reliability and validity. Results: Most measures were newly developed or built on the Smoking Consequences Questionnaire. Few measures assessed perceptions of non-cigarette products, and some health harms rarely were assessed. Few measures specified product use conditions. Over half of studies assessed reliability, which was typically high. Most assessed validity by comparing scores by use status, finding mixed results. Conclusions: Several measures of cigarette risk perceptions included a range of health effects and demonstrated reliability and validity, though they had other shortcomings (eg, they did not specify conditions of use). Researchers could help address gaps in measuring tobacco health perceptions by developing quality consensus measures for non-cigarette products, assessing a range of perceived health effects, assessing perceptions relative to other products, specifying use conditions, and showing multiple types of validity in diverse subpopulations.

Cigarette and smokeless tobacco company smartphone applications.

PURPOSE: Two previous studies indicate that prosmoking apps might encourage smoking behaviour via smoking cues. The current paper seeks to build on these studies and provide an updated overview of the characteristics of tobacco industry-sponsored apps. METHODS: In November 2017, we identified 19 unique top-selling cigarette brands, 20 smokeless tobacco brands, 30 e-cigarette brands and 43 cigar brands based on Nielsen sales from 2016 Nielsen Scantrack data and 2016 Kantar advertising data from the Kantar Media Stradegy database. We searched for these brand-sponsored apps in the Google Play and Apple iTunes US online stores. RESULTS: We identified four cigarette and one smokeless tobacco brand-sponsored apps on the Google Play store, but none in the Apple store. The apps sponsored by Grizzly, Newport, Skoal, Camel and Winston used the last four digits of the users' social security number to verify age. The Marlboro app offered another option in addition to providing a partial social security number-providing a valid home address. The main feature of all apps was location-based, time-sensitive coupons. Some apps had additional functions such as additional detailed product information, interactive help menus and games. DISCUSSION: This paper provides an up-to-date description of apps that are sponsored by tobacco companies. Cessation interventions could consider reminding their target audience to delete these apps to support quit attempts.

Mobile website characteristics of leading tobacco product brands: cigarettes, smokeless tobacco, e-cigarettes, hookah and cigars.

SIGNIFICANCE: Most US adults use smartphones for internet access. Understanding what they see when they view smartphone-optimised (mobile) tobacco websites is important, as it can inform tobacco education and cessation strategies. This study describes mobile tobacco websites for leading brands of cigarettes, cigars, smokeless tobacco (smokeless), e-cigarettes and hookah. METHODS: We identified 130 leading tobacco brands based on sales, advertising spending and self-report data. Of these, 62 brands had mobile websites. We conducted an inductive content analysis (ie, where we derived the coding scheme from what we observed) of website characteristics by dual-coding: age requirements, warning display, brand engagement methods (eg, social features) and sales strategies (eg, coupons). RESULTS: All cigarette and most smokeless websites required age-verified accounts for entry, while 76% of e-cigarette websites required accounts only for making purchases. All cigarette and smokeless websites showed warnings, but a minority of e-cigarette and cigar websites did, and no hookah websites did. Many websites required users to scroll up to view warnings. Most e-cigarette websites, most hookah websites, and half of cigar websites linked to multiple social media platforms; however, most cigarette and smokeless websites facilitated socialisation internally. All cigarette, most smokeless and no hookah websites offered coupons. Many cigarette and smokeless coupons were time-sensitive and location-based. CONCLUSIONS: We highlight issues in how tobacco brand websites address youth access, display warnings, engage consumers and facilitate purchase. Results can help public health educators and practitioners better understand tobacco marketing as a context for designing tobacco interventions.

Harm Perceptions of Intermittent Tobacco Product Use Among U.S. Youth, 2016.

PURPOSE: We aimed to describe U.S. youth harm perceptions of intermittent tobacco use. METHODS: Using data from the 2016 National Youth Tobacco Survey of U.S. students (grades 6-12; N = 20,675), we examined prevalence and correlates of all respondents' perceived harm of using four different tobacco products on "some days but not every day." Associations between current (past 30-day) use and harm perceptions were assessed using multivariable regression. RESULTS: Perceiving that intermittent use causes "no" or "little" harm was 9.7% for cigarettes, 12.0% for smokeless tobacco, 18.7% for hookah, and 37.5% for e-cigarettes. Compared with those who reported "a lot" of harm, youth with lower harm perceptions were more likely to report current use. CONCLUSIONS: One in ten youth perceived intermittent cigarette smoking as causing "little" or "no" harm; this perception was higher among current users. Efforts to educate youth about the risks of even intermittent tobacco product use could reduce misperceptions of harm.

US Adult Interest in Less Harmful and Less Addictive Hypothetical Modified Risk Tobacco Products.

Introduction: Tobacco companies have a history of making health claims about their new products. Such claims are now regulated by the US Food and Drug Administration. We examined consumer interest in hypothetical modified risk tobacco products (MRTPs) among current, former, and never established smokers and examined whether interest was associated with beliefs about tobacco and cancer. Methods: Data were analyzed from the US nationally representative 2015 Health Information National Trends Survey (HINTS-FDA 2015; N = 3738). Interest in hypothetical MRTPs was assessed by asking participants their likelihood of using tobacco products claiming to be less addictive and less harmful than other products. Results: About half of current smokers and a tenth of both former and never smokers reported they were "somewhat" or "very" likely to try hypothetical MRTPs claiming to be less harmful or less addictive. Female smokers, former smokers with lower smoking harm perceptions, and never smokers who are young adults or without college education expressed more interest in these products. Interest in using these products was positively associated with believing that smoking status is a changeable individual characteristic and that it is possible for tobacco products to be made without some harmful chemicals. Conclusion: We identified several subgroups of current, former, and never smokers who may be particularly affected by the marketing of MRTPs and therefore important to study to inform models of the potential population health impact of authorizing the marketing of MRTPs. Implications: Findings about interest in hypothetical MRTPs can inform models of how the marketing of MRTPs could affect population health. Understanding which subgroups are particularly interested in MRTPs can help determine who might be important to study to inform these models. We identified several groups who may warrant specific attention: smokers who are female, former smokers who hold low harm perceptions of smoking, never smokers who are young adults or have a high school education or less, people who believe that smoking is a changeable individual characteristic, and people who believe that it is possible to make low chemical tobacco products.

Racial and Ethnic Differences in Tobacco Information Seeking and Information Sources: Findings From the 2015 Health Information National Trends Survey.

This article describes sources of health information, types of tobacco information sought, and trust in sources of tobacco information among U.S. racial/ethnic groups (Whites, Blacks, Hispanics, Asian and Pacific Islanders, and Other). Cross-sectional data (N = 3,788) from a nationally representative survey, HINTS-FDA 2015, were analyzed to examine unadjusted and adjusted associations between race/ethnicity and (a) first source of health information, (b) tobacco information seeking, and (c) trust in sources of tobacco information. Adjusted associations controlled for current tobacco product use and sociodemographic variables. Findings indicated that the Internet was the most common first source of health information while health care providers were the second most common source for all racial/ethnic groups. Tobacco-related health information seeking was more prevalent than other tobacco product information seeking. Unadjusted analyses indicated that a higher proportion of Whites sought other tobacco product information compared to Asians and Pacific Islanders. Trust was rated highest for doctors while trust for health organizations was rated second highest. Asians and Pacific Islanders had higher trust in the government compared to all other groups. Blacks had higher trust in religious organizations compared to all other groups besides Hispanics. Blacks had higher trust for tobacco companies compared to Whites and Other. Many of these differences were attenuated in adjusted analyses. This research has implications for tobacco control practice and policymaking by identifying potential dissemination strategies.

Measuring youth beliefs about the harms of e-cigarettes and smokeless tobacco compared to cigarettes.

This study examined validity of direct and indirect measures of perceived harm of e-cigarettes and smokeless tobacco (SLT) compared to cigarettes. On direct measures, people compare one product to another, whereas on indirect measures, people rate each product separately and the researcher compares these ratings. Data from youth in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014) were analyzed (N=13,651 youth aged 12-17years). The study included direct measures of perceived harm of e-cigarettes and SLT compared to cigarettes, and indirect measures were created by comparing ratings of the products. Weighted multinomial logistic regressions tested criterion validity by assessing whether direct and indirect measures were associated with criterion variables, including use of e-cigarettes and SLT. Youth were more likely to rate e-cigarettes as less harmful than cigarettes on the indirect measure (67.3%) than the direct measure (50.2%). The same pattern held for ratings of SLT as less harmful than cigarettes (indirect: 29.7%; direct: 11.7%). Direct measures explained unique variance in product use criterion variables even after adjusting for indirect measures, as did indirect measures after adjusting for direct measures. However, the criterion variables were more often associated with the direct measures than the indirect measures. Results offer preliminary support for using both direct and indirect measures when assessing youth's perceived relative harm of various types of products. However, if researchers cannot include both direct and indirect measures in a study, associations with product use criterion variables support prioritizing direct measures.

U.S. adults' addiction and harm beliefs about nicotine and low nicotine cigarettes.

This research described U.S. adults' beliefs about nicotine and low nicotine cigarettes (LNCs) using the nationally-representative Health Information National Trends Survey (HINTS-FDA 2015; N=3738). About three quarters of people either were unsure of the relationship between nicotine and cancer or incorrectly believed that nicotine causes cancer. People who were non-White, less educated, age 65+, and never established smokers were most likely to be unaware that nicotine is not a cause of cancer. More than a quarter of people held the potentially inaccurate beliefs that LNCs would be less harmful and addictive than typical cigarettes. Whites were more likely than Blacks to believe LNCs were less harmful than typical cigarettes, and never smokers were more likely to believe this than established quitters. Whites and people with at least a college degree were more likely to believe that LNCs would be less addictive than typical cigarettes. Overall, we found that many people, particularly the demographic subgroups identified here, held incorrect beliefs about nicotine and potentially inaccurate beliefs about LNCs. Findings should be considered in assessing the public health impact of marketing low nicotine products. Incorrectly believing that nicotine causes cancer could discourage smokers from switching to safer nicotine-containing alternatives, and could lead nonsmokers to experiment with low nicotine tobacco products, believing that cancer risk would be reduced. Findings underscore the need to educate the public on the health effects of nicotine and LNCs, and can help public health practitioners determine which subgroups should be prioritized in targeted educational efforts.

The relationship between shame and perceived biological origins of mental illness among South Asian and white American young adults.

Mental illness (MI) affects one in four people in their lifetime and a failure to seek help for MI can have grave consequences. To decrease stigma and increase help seeking, prior campaigns have promoted the biological origins of MI. Even though some research supports the efficacy of this approach, other research does not. We propose cultural differences as a partial explanation for these inconsistent results. The current study assessed ethnic differences in the relationship between perceived causes of MI, shame associated with MI and perceived family support for help seeking. White and South Asian American (SAA) undergraduate students completed an online survey (n = 177). Results indicated that SAAs were significantly more likely than whites to perceive character deficits as the cause of MI. Further, among those who had sought help for MI, ethnic differences emerged in perceptions of MI based on perceived cause. SAAs who believed that MI had biological origins perceived more shame and less family support for seeking help compared to SAAs who believed MI was due to character deficits. The converse was true for whites - those who believed that MI had biological origins perceived less shame and more family support for help seeking compared to whites who believed MI was due to character deficits. The results of the current study illuminate the role that culture plays in perceptions of MI. Further, these results have implications for interventions targeting South Asian populations and for mental health outreach in general.